Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Megan Lawrence-Ferreira. Administrator informed LPA that they have reviewed PIN 22-07, 22-09 and PIN 22-13.

LPA arrived at the facility and have their temperature checked and logged into a sign-in sheet. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least two times a day. Facility is allowing indoor visitations and has antigen tests available to use for visitors. Facility is able to accommodate a single room for each client that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and has been N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has 100% vaccination rate and boosters for all staff and clients. Three out of three clients do attend to day program two days per week in average and the facility also provides activities. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has submitted their Covid Mitigation Plan and approved on 5/28/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff.

Administrator provided updated copies of the following: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E) and surety bond.