Facility Evaluation Report

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 06/20/2022 at 12:45 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with staff Judieta Duenas and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator/Licensee Maria Weneliza Cabahug was contacted and informed of the visit. Staff Duenas reported that they have three (3) clients at the facility. Licensee/Administrator Cabahug arrived during the visit. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Licensee/Administrator Cabahug. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing, and signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect clients from infection during pandemic. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE, LPA Brown went over the various recommended training for facility staff with Licensee/Administrator Cabahug in relation to COVID-19 and Licensee/Administrator Cabahug informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and Licensee/Administrator Cabahug informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, LPA Brown observed all clients andall staff have been vaccinated and boosted and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.