Facility Evaluation Report

On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility administrator and let him know the purpose of today's visit. Upon entry LPA had temperature taken and answered COVID protocol questions as well as signing the visitor log book.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings and hand washing signs are present inside the facility on both floors in hallways and doors. Hand sanitizer is observed as readily available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medication room is observed as in order and door is locked. First aid kit is observed as in place in medication room. Toilet and bathing facilities are equipped with grab bars and some showers equipped with non-slip surfacing. Liquid soap is available. Paper towels are present for resident use. Water temperature is taken on lower level common bathrooms at 110F. Upper level bathroom water temperature was tested at 110F. LPA observed 3 resident rooms and all had required furniture, lighting, linens and were in clean condition. Laundry machines and dryers are observed as functioning. Emergency food supply, dry goods, and perishables are observed as in place. Communal dining room is observed as in order with COVID postings present. Facility has sprinkler system installed and last inspected in May 2022. Fire extinguishers are charged ready for use last stamped as inspected on 4/15/22.

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 records and they are current. LPA sampled staff first aid cards and training records and they are current. Resident temperature logs and staff logs are current. All staff and residents are vaccinated according to the administrator. Facility does PCR testing ever week via a private company requiring staff to be tested at least every other week. Residents are PCR tested every other week. Facility handles client P&I monies. This was audited and accurate.

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 finger print cleared and associated to the facility. Administrator certificate is viewed as current expiring 3/3/2024. Mitigation plan is reviewed with the administrator and is current. Infection control plan is current.

LPA is requesting the following forms to be updated and :

• LIC 308 Designation of Administrative Responsibility

• LIC 400 Affidavit regarding client cash resources

Report is reviewed with administrator. No deficiencies cited today.