Facility Evaluation Report

Licensing Program Analyst (LPA) Katrina Walters arrived unannounced to conduct a Required 1-Year Inspection and met with Administrator, Imee Villegas. The inspection is focused on the Infection Control procedures and practices of this facility.

At primary entrance LPA observed temperature logs and visitor sign-in sheet. N-95 mask, disposable gowns, and hand sanitizer were available for visitors. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan and Infection Control Plan was submitted and available for review.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Updated infection control guidelines and PINs are sent to the families and responsible parties. Staff have completed Personal Protective Equipment (PPE)/infection control training. Administrator maintains a binder with current COVID-19 protocols and contingency plans. Staff keep inventory of PPE. Inventory of PPE is stored in garage and Staff room. LPA confirmed facility has at least a 30-day supply of PPE and incontinence products. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. Residents' emergency contact information has been updated and administrator confirmed staff are familiar with emergency procedures and protocols. Toxins are secured and inaccessible to residents. Medications are centrally stored in a locked. All staff and residents are vaccinated and boosted.