Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and was greeted by facility staff. Administrators, Maria Tatad and Roselyn Jequinto arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that the facility has Covid related posters on the exterior door as well as a hand sanitizer receptacle. LPA's temperature was checked upon entry to the facility. Sign-in document for visitors includes standard Covid-19 screening questions. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility specifically outside of each client room. Clients are encouraged to wear masks when in the community and staff are required to wear them while in the facility. Observed staff had masks on during this visit.

LPA and Administrators discussed client activities and visitation. Facility has a designated visitation area.

Caregivers have completed Personal Protective Equipment (PPE_ training and have been N-95 Fit tested. Commonly touched surfaces are disinfected on each shift.

Facility has submitted their Covid Mitigation Plan and it has been reviewed by CCL. Facility has more than a 30 day supply of PPE including but not limited to masks, face shields, gowns and hand sanitizer. PPE is accessible to staff who need it. Facility maintains a 30 day supply of medication.

LPA confirmed that unvaccinated staff are being tested weekly per current CCL guidance. LPA also discussed the most recent PINs that have been sent out by the Department including but not limited to PIN 21-44-ASC and PIN 21-40-ASC .

Administrators and LPA discussed their Emergency Disaster Plan

No deficiencies cited during this inspection.