Facility Evaluation Report

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 05/11/2022 at 12:45 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Harold de Jesus 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 de Jesus. Per documents review, Mitigation Plan was submitted 01/03/2021.

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's client bedrooms and bathrooms and observed that both client 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. LPA Brown went over the various recommended training for facility staff with Administrator de Jesus in relation to COVID-19 and Administrator de Jesus 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 Administrator de Jesus informed LPA Brown that no staff had 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 having COVID-19 positive client last 12/29/2021, and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results.