Facility Evaluation Report

Licensing Program Analyst, Amber Coleman (LPA) arrived at the OPARC - Montclair Adult Day Program facility to conduct an Annual Inspection with a focus on Infection Control. LPA introduced self to staff upon arrival and stated the purpose of the visit. LPA was asked to have temperature taken and complete sign in sheet. While signing in LPA observed PPE, hand sanitizer and disinfectant made available to staff, clients and visitors. Annabell Hernandez, introduced herself as Program Manager (PM). LPA was provided space to work and taken on a tour of the facility. All staff members were observed wearing appropriate PPE.

PM reports that there are currently no clients diagnosed with COVID. The current census is 27 and they are vaccinated with an exception of 4. All 17 staff members are vaccinated with no concerns of COVID.

During the inspection, LPA conversed with PM regarding the facility's infection control measures and other health and safety concerns. LPA observed necessary signs posted through out the facility, including signs related to COVID-19, which were in accordance with the Department's guidelines. PM showed LPA that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation of clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

The facility conducts Emergency Fire Drills with staff and clients on a monthly basis. Last fire drill completed on 12/9/22. Documentation reflects nothing abnormal. Client and staff files are kept at a centralized location and made available upon request. LPA reviewed 3 charts, of 3 charts contained sufficient information.

During the tour of the facility, LPA observed the facility side fence gate secured with pad lock. LPA informed Program Manager that the facility fence side gate must not be locked as this poses immediate risks to residents in care; in that they will not have the ability to evacuate in the event of an emergency. LPA will be issuing a Technical Assistance Advisory Note instead of a deficiency due the frequency of fire drills and inspections conducted. Immediate assistance is made readily available. Additionally, PM removed the lock from the gate during visit.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.