Facility Evaluation Report

On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility LVN and let her know the purpose of today's visit. Upon entry LPA observed COVID postings upon entry to the facility on front door. LPA signed in and had temperature taken.

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. Hand sanitizer is observed as available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medications are locked and not accessible in a medication cart located in the living area of the facility. First aid kit is observed as in place. 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 common bathrooms at 120F. Laundry machines and dryers are observed as functioning in facility garage. Emergency food supply, dry goods, and perishables are observed as in place. Fire extinguishers are charged ready for use.

Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Medications, toxins are stored appropriately and inaccessible to clients. LPA reviewed staff records on this day. Resident temperature logs and staff logs are current. LPA reviewed COVID vaccine documentation. All staff and residents are fully vaccinated per the records reviewed.

A disaster and mass casualty plan is present. 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. Infection control plan and mitigation plan is current. Administrator certificate is observed expiring on 1/1/2023. Facility does not handle P&I monies for clients in care.

LPA is requesting the following updated forms to be sent to the Department by 8/31/22 :

• Copy of current administrator Certificates

• LIC 308 Designation of Administrative Responsibility

Report is reviewed with administrator Roger Fuji. No citations issued.