Facility Evaluation Report

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/22/2022 at 01:00 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Carmen Cuellar 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 Brown went over COVID-19 best practices for infection control and prevention with Administrator Cuellar and Administrator Cuellar reported that Mitigation Plan was submitted 01/20/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility and observed that client bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, and face shields/goggles and isolation gowns. LPA Brown went over the various recommended training for facility staff with Administrator Cuellar in relation to COVID-19 and Administrator Cuellar reported that all staff were 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 Cuellar informed LPA Brown that all staff have been N95 fit tested. Administrator Cuellar showed proof of completed N95 respirator fit testing for all staff to LPA Brown. Also, LPA Brown informed Administrator Cuellar that N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, Administrator Cuellar reported that all residents and most staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.