Facility Evaluation Report

On 12/21/22 at 2:30 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Staff #1 (S1) and explained the purpose of the visit. At 2:35 pm, Donna Pieprzycki, RN Consultant, arrived at the facility, and LPA explained the reason for the visit.

LPA toured the facility with S1 and observed the following: The facility has infection control signage at the front entrance and throughout the facility on handwashing, cough etiquette and use of masks. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguishers (2) are located in the hall near the laundry room and the hall near resident bedrooms on the east end of the facility. The extinguishers are fully charged and were inspected on 12/8/22 and 12/2/22 respectively. LPA observed cleaning supplies and hand sanitizer in an unlocked cabinet in the staff bathroom which is also unlocked. Nurse consultant immediately moved supplies to the locked closet at the entryway. Nurse consultant committed to writing a statement showing that quarterly trainings with staff will be conducted on proper storage of toxins and will send statement to CCL by 12/28/22. LPA took water temperatures and from 2:59 pm to 3:05 pm, the sink’s water temperature in the residents’ bathroom near the office was 70.5F degrees. Per CCLD Health & Safety regulation water temperatures are to be between 105F and 120F degrees. Citation issued.

At 3:30 pm, LPA conducted the Infection Control mitigation module with the nurse consultant. No deficiencies cited from the module.

Exit interview conducted, deficiency cited, and the report and appeal rights emailed to the administrator and nurse consultant.