Facility Evaluation Report

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with caregiver Vincent Cabauatan and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with caregiver Vincent Cabauatan, who LPA Colvin found to be successfully incorporating the several aspects of the infection control, despite not having a Mitigation Plan on file. LPA Colvin inquired about if there was a copy at the facility for LPA Colvin to review (as there is no evidence that one has been submitted to Licensing) and the caregiver Vincent Cabauatan stated that there is not. LPA Colvin will be issuing a Technical Advisory Note for the facility not having a Mitigation Plan. LPA Colvin will not be issuing a deficiency as the Mitigation Plan request/requirement is outdated, and facilities are now being advised to submit an Infection Control Plan. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns). LPA Colvin observed the facility to not have an adequate supply of PPE, and caregiver Vincent Cabauatan was unaware of where additional PPE might be located. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note for the facility not having a 30-day supply of PPE. LPA Colvin went over the various recommended training for facility staff with caregiver Vincent Cabauatan in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and caregiver Vincent Cabauatan informed LPA Colvin that they have. LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. caregiver Vincent Cabauatan confirmed that residents are being screened daily.