Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with staff Elizabeth Ramirez. Licensee was not able to come to the facility, but was able to give authorization for staff to sign the report. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility is a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE, but have not been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguisher was last serviced within the last 12 months. Last disaster drill was conducted on December, 2022. One out of two clients do attend to day program and facility provides activities for clients as well.

Licensee will provide copies of the following documents by 3/6/23: LIC 308 Designated Administrator, LIC 610 Emergency Disaster Plan, LIC 500 Personnel Summary, LIC400 affidavit regarding client cash resources and surety bond.

No deficiencies cited during today's inspection. Exit interview conducted with staff and a copy of this report was given.