Facility Evaluation Report

Licensing Program Analyst (LPA) Canela arrived unannounced, to conduct an Annual Required 1 YR inspection and was greeted by care staff, Lupo Canilao and Julita Gozos, Administrator was called and arrived towards the end of the inspection. The inspection is focused on the Infection Control procedures and practices of this facility, that is licensed for up to 6 non-ambulatory residents of which 3 may be on Hospice services and no rooms are approved for bedridden.

Upon arrival, LPA observed that facility has Covid posters on the front door. . Once inside the facility, LPA observed that facility has a sign-in for visitors, screening area with PPE . LPA observed that staff were wearing masks during today's visit. LPA conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms, but no paper towels. Facility was a comfortable temperature. Residents are encouraged to wear masks when in the community. Commonly touched surfaces are disinfected daily.

Facility staff have been trained on PPE Facility has submitted their Covid-19 Mitigation Plan and Infection Control. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is in a location that is stored and accessible to staff. Facility maintains a 30 day supply of medication. Fire extinguisher was charged and last serviced 8/19/2022. Smoke alarms and carbon monoxide are operational.

LPA consulted regarding the backyard left gate latch that is getting tight and will need to be changed or fixed. The dining room sliding door screen handle needs to be repaired and the bottom track cleaned or corrected for the door to slide easy. LPA also requested facility to review if there is a problem with R1s television and that television is located where R1 can properly observe television.