Facility Evaluation Report

Licensing Program Analyst (LPA) A. Canela arrived at this facility, unannounced, to conduct a Case Management Legal/Non-Compliance follow up visit. This inspection is being completed to ensure compliance with a Non-Compliance Conference dated 11/5/2020. LPA met with Licensee/ Administrator, Cecilia Ganzon and Christine Daquioag. The facility was toured and LPA made observations and reviewed records.

LPA toured the facility with the facility Administrator and the following was observed: Staff working today were observed wearing mouth coverings. There is an entrance table with PPE supplies and staff screened LPA upon arrival. The facility has several sections with PPE tables throughout the facility hallways. Water temperature in 2 bathrooms were within the required regulation of 105-120 degrees F. LPA went in all 9 resident bedrooms of the first level of the home and resident rooms were found free of odors as requested in non-compliance plan by CCL for the facility to ensure the facility remains free of odors from incontinence. Auditory alarms were observed functional during this visit.

Staff follow indoor visitation requirement of verifying/tracking COVID-19 vaccination or a negative COVID test for visitors.

Upon arrival to the facility, staff S1 got to the door and turned around to run and get a key to open the door. LPA observed that facility staff had to use a key to open the entry door key lock, so the door could open. LPA explained to staff, this was a zero tolerance violation and for the safety of the residents and staff, the door should be able to open incase of a fire. LPA toured the side backyard gates and observed the right side gate would not open, the latch is on the wrong side of the door and the latch was tangled and tied with string to prevent the door from opening from the backyard. This facility does not have approval from the Fire department or CCL for a locked perimeter.

Continue report and citations, see LIC809-C and LIC809-D