Facility Evaluation Report

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/11/2022 at 09:30 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Business Services Director Priscilla Mancilla 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 Business Services Director Priscilla Mancilla and per file 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. LPA Brown toured the facility's and observed that resident 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, isolation gowns, face shields/goggles.

LPA Brown went over the various recommended training for facility staff with Business Services Director Priscilla Mancilla in relation to COVID-19 and Business Services Director Priscilla Mancilla 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 Business Services Director Priscilla Mancilla informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a deficiency for this item due to the facility recently have a COVID-19 positive staff last 02/25/2022, and N95 masks needs to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Also, LPA Brown observed that most residents and staff have been vaccinated and are practicing other COVID-19 precautions. *** Continuation in LIC809C ***