Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility caregiver Emma Advincula and let her know the purpose of today's visit. Upon entry LPA had temperature taken but not asked COVID symptoms questions. LPA did observe no staff wearing masks upon entry. Masks were later worn by staff during the inspection. LPA later met with the licensee Cynthia Advincula who arrived during the inspection.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings are not present on the front door or inside the facility. Hand washing signs are observed in resident bathrooms. Hand sanitizer is observed as available near the front door of the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medications and knives are observed as locked and not accessible to residents. First aid kit is observed as complete. Toilet and bathing facilities are equipped with grab bars and non-slip mats. Liquid soap is available. Paper towels are present for resident use. Water temperature is taken in a common resident bathroom at 120F. Laundry machines and dryers are functioning. Emergency food supply, dry goods, and perishables are observed as in place. Fire extinguisher located in dining room/kitchen are is observed as inspected on 2/15/2022. Appears to be charged and ready for use.

Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins are stored appropriately and inaccessible to clients. LPA reviewed training record. Resident temperature logs and staff logs are current. All staff are vaccinated and boosted. Residents are vaccinated and boosted. Facility PPE supplies are observed as in place.

A disaster and mass casualty plan is present and current. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. LPA identified two staff, S1 and S2, that are not associated. Administrator certificate is viewed as current expiring 10/05/2023. LIC808 is discussed and is not current LPA is requesting updated LIC808 to be sent to licensing by 08/12/2022

LPA is requesting the following updated forms to be received by 08/12/2022 :

• LIC 308 Designation of Administrative Responsibility

Civil penalty is being assessed today at $100 x 2 (two staff not associated) = $200

Report is reviewed with administrator. Deficiencies cited on the following 809D.