Facility Evaluation Report

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 06/17/2022 at 12:40 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with staff Rebecca Pantoja and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Staff Pantoja reported that they have five (5) 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 Staff Pantoja. Per documents review, Mitigation Plan was submitted 07/27/2021.

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's 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. LPA Brown went over the various recommended training for facility staff with staff Pantoja in relation to COVID-19 and staff Pantoja 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 staff Pantoja informed LPA Brown that two (2) staff have been fit tested but unable to show proof of completed N95 respirator fit test. Staff Pantoja also added that the rest of the staff already have an appointment scheduled for 06/22/2022 for N95 fit test. LPA Brown will be issuing a deficiency for this item due to the facility recently had COVID-19 positive clients last 01/21/2022, and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results LPA Brown observed most clients and most staff have been vaccinated and boosted and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.