Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct an Required-1 Year inspection and met with Sandra Ambrecht, lead caregiver/back-up to the Administrator. This inspection is focused on the Infection Control procedures and practices of the facility.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. The new updated Infection Control Plan was recently submitted as required by the Department. Fire clearance is approved for six (6) non-ambulatory. There were six (6) residents in care at the facility during the inspection. Residents are screened daily, and observed for any changes, all information is logged. Facility was found to be at a comfortable temperature for the residents in care. LPA observed all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) for use by staff and others, residents and/or visitors as needed or wanted. Staff Sam was observed wearing a mask, as required, upon LPA's entry into the facility.

LPA observed the following during the inspection: Staff didn't screen the LPA upon entry and/or at any time ask to screen the LPA. The LPA discussed the screening requirements with staff Sam. This deficiency will be cited, Administrator Qualifications and Duties 87405(d)(2)-see LIC809D.