Facility Evaluation Report

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 07/20/2022 at 09:30 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with staff Danilo Millan and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator Neil Consuelo was contacted and arrived during the visit. Administrator Consuelo reported that they have four (4) clients at the facility. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Consuelo. Per documents review, Mitigation Plan was submitted 05/11/2021.

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 toured the facility, and all rooms and bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE except for face shields. LPA Brown will be issuing Technical Advisory Notes for only having one (1) face shield available at the facility. LPA Brown went over the various recommended training for facility staff with Administrator Consuelo in relation to COVID-19 and Administrator Consuelo reported to 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 Administrator Consuelo informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks due to the facility recently have two (2) Covid-19 positive clients and one (1) Covid-19 positive staff last 05/20/2022, and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results.