Facility Evaluation Report

Licensing Program Analyst (LPA) Dina Alviso conducted a 1 year required inspection and met with Administrator Stephanie Limberg. The inspection is focused on the Infection ontrol procedures and practices of this facility.

Currently 52 residents in care. Hospice care waiver approved for thirteen(13) residents. Mitigation plan submitted and reviewed by the Department. Fire clearance approval is for 80 non-ambulatory residents, which includes 4 bedridden.

The Administrator notified the LPA that she is conducting random surveillance testing today with staff. The LPA toured the facility with the Administrator. Facility has sanitizer available in the entry area, and this is where all staff and visitors are screened, and temperatures taken. All screenings are logged. Facility was found to be clean, orderly, and at a comfortable temperature. LPA observed exits free from obstruction. Sufficient supply of hygiene products, cleaners, and paper products for use as needed. Sufficient food supply. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) within the facility and in an outside garage storage. Residents have masks available to them for their use if needed and/or wanted. Administrator stated that all staff wear masks in the facility, including when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection, and all the staff the LPA observed during the inspection. The hot water is at a hot water temperature of 110.F -118.F. The LPA reviewed the hot water temperature log the Administrator sent to the LPA, and the LPA observed the three hot water boiler tanks which were all at the holding temperature of 140 which will mix with the cold water as it is delivered out to facility pipes. LPA observed the stairwells, and the evacuation chairs were in place, including the instructions on their use in an emergency. LPA observed emergency bins with all supplies stocked with listing of supplies, to be used in an emergency as needed. This supply included first aid kits, flashlights and batteries.