Facility Evaluation Report

Licensing Program Analyst (LPA) K.. Hiratsuka, arrived at the facility unannounced on 01/06/2022 to conduct an unannounced annual visit using the infection control tool visit. LPA met with Facility Administrators Anna and Elena Polyakovar, and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPA ensured they wash hands shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Administrator.

LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

Exit interview conducted and copy of report left at the facility.

The following shall be updated and submitted to Community Care Licensing by 01/31/2022:

-LIC 500 facility personnel or staff schedule

-LIC 308 designation of administrative responsibility