Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and initially met with facility staff. Administrator, Mharc Dela Rama arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors that they will be screened and the visitation policy of the facility. LPA was screened at the front door by a staff and then asked to enter through the backyard per the facility's protocol. LPA initiated a walk-through of the facility around 9:20am and observed the following: LPA was shown the screening area in the garage where staff are screened prior to coming on shift. LPA reviewed staff and client screening documentation. Clients are screened twice per day. LPA confirmed with staff and Administrator that staff are conducting vaccination verification for visitors per Provider Information Notice (PIN) 21-40-ASC Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is locked to ensure client safety but hand washing supplies are located at sinks and clients are given hand sanitizer when needed. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected twice per shift.

Staff continue to be training regarding infection control and donning and doffing of PPE. Staff have been N95 fit tested. Administrator and LPA discussed re-testing staff for N-95 mask wearing. LPA and Administrator discussed visitation and activities.