Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 11/07/2022 at 03:00 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with Licensee/ Administrator, Yvonne Holcombe , who was informed of the purpose of the visit. At the time of the visit there were (2) staff and (2) residents present.

LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point where screenings are conducted for facility visits. LPA observed COVID-19 postings throughout the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents and staff. The facility has a designated visitation area in the facility. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels.

The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. The staff have not yet been FIT tested for an N95 respiratory. LPA documented a technical advisory note.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to Licensee/ Administrator, Yvonne Holcombe