Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Tess and Rene Manuel. The focus of the visit was Infection Control. Administrator Minerva Sansano was contacted. LPA spoke with her about Licensing Fees, Administrator Certification and Associations. She stated that she could not come to the facility and assured LPA that she would bring her facility into compliance. During the visit LPA toured the facility and the following was observed:

Covid signage was not posted at the front entrance of the facility . There was a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was made available. Facility has required Department postings. Ms. Sansano is reminded that all staff need to be associated through Guardian. Civil penalties will be issued if not completed. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were observed having lunch and resting in their rooms. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review PIN 20-17.2-ASC in regards to Visitation, dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. as well as PIN 21-32-ASC Updated Facility Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Rene Manuel.