Facility Evaluation Report

Licensing Program Analyst (LPA) Marisol Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator, Lora Navarro and another staff.

LPA arrived at the facility and was not screened by Administrator. TA advisory was issued for Administrator and we discussed the importance of screening visitors. However, Facility continues to screen clients for Covid-19 daily and maintain documentation. Facility is allowing indoor visitations, each client has their private room and is able to serve meals and deliver medications. LPA observed that staff were wearing masks during this visit. LPA/Administrator 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 twice a day. LPA confirmed with Administrator that facility was conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. Facility staff have been trained on PPE protocols and has been N-95 fit tested.

Facility maintains a 30 day supply of medication. All clients do not attend to day program due to health concerns; LPA and Administrator discussed activities and the facility 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 4/29/21. Facility submitted their Infection Control Plan to CCL for review. 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. Staff continue to receive training on infection control and Personal Protective Equipment (PPE).