Facility Evaluation Report

Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct Required - 1 Year inspection at 8:45 AM, and met with administrator, Kimberly Fernandez. LPA was initially greeted by staff, administrator arrived shortly. The inspection was focused on the Infection Control procedures and practices of this facility.

Upon entry staff took LPA's temperature. Posted at the entrance above the visitor sign in sheet were a series of screening questions. COVID postings were observed posted at the front door. Mitigation plan has been submitted and reviewed by Community Care Licensing (CCL).

LPA conducted walk through of the facility with administrator. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training through Elwyn. Staff have been N95 fit tested by Elwyn. High touch surface areas are disinfected daily. There is a cleaning sheet/log which details when surfaces are disinfected. Due to current facility census clients could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE and supplies to support a client in isolation.

Clients' emergency contact information has been updated and administrator confirmed staff confirmed they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked cabinet inside the laundry room. Medications are centrally stored and locked on the medication cart. The facility has hygiene supplies and PPE located in hallway closet.

Facility is not currently conducting surveillance testing. Facility has a 100% vaccination rate for both staff and clients.