Facility Evaluation Report

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Gardner met with Administrator Steven Rajadas who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit there were three (3) staff and thirteen (13) residents present.

LPA Gardner went over COVID-19 best practices for infection control and prevention with Steven Rajadas. The residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA Gardner observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, and social distancing. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the bathroom cabinet. The facility has a limited supply of PPE. The facility was notified that they need to obtain a full 30-day supply of PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer. LPA Gardner inquired as to if staff have been fit tested for N95 masks and was told their staff have not been fit tested yet. LPA Gardner will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks and for not having a full thirty (30) day supply of PPE. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

During today’s visit it was found that staff (S1) does not have a criminal record clearance.