Facility Evaluation Report

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with Caregiver Filomena Centeno who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit there were 2 staff, and 4 residents present. Staff phoned Administrator Gloria Cabebe who arrived during today's visit. LPA went over COVID-19 best practices for infection control and prevention with Ms. Cabebe. The facility does not have a mitigation plan on file with CCL. LPA spoke to Ms. Cabebe regarding the mitigation plan needed for the facility. LPA was notified by Ms. Cabebe that the mitigation plan will be mailed to CCL. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for not having a COVID-19 Mitigation Plan on file. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for residents has been updated. LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the in the hallway cabinet. Ms. Cabebe has a limited supply of PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer supply. LPA and Ms. Cabebe discussed obtaining a full 30-day supply of PPE. As well as creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for not having a full 30-day supply of PPE. LPA inquired as to if staff have been fit tested for N95 masks, and Ms. Cabebe stated their staff have not been fit tested yet. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

Continued on LIC 809C form...................................................................................................................