Routine inspection·October 27, 2021

Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator (ADM) Anabelle Galera, who is the designated Infection control leader. LPA inspected the facility inside and outside. A certified administrator is on site at all times to oversee proper business operation and compliance with COVID-19 infection control practices. LPA observed that 4 of the 4 staff present wore face masks at all times. All of the staff and residents were fully vaccinated. LPA observed a screening station located near the front entrance with hand sanitizer, a no-touch thermometer, visitor's log, and face masks as needed. LPA observed COVID-19 signs posted in common areas to promote hand washing and physical distancing. Staff documents temperature and health status for staff and residents on a daily basis. LPA discussed the mitigation plan with the Licensee, as well as their current COVID-19 infection control practices. The Licensee has conducted staff training on infection prevention, symptoms, transmission, as well as the proper donning and doffing of PPE and they have adequate PPE supplies on hand in case of an outbreak. However, there were areas where the LPA provided Technical Assistance because the staff were not asking for or recording vaccination status for visitors, nor had FIT testing been completed for all staff members. The LPA gave the Licensee tasks to overcome those missing areas detailed in the Technical Assistance forms. The room temperature of the facility was maintained at a comfortable temperature and hot water was within the safe temperature of 105 to 120 degrees Fahrenheit. There were sufficient food and water supplies in the kitchen refrigerators/freezers. Fire extinguishers were observed fully charged and last inspected in October 2021 and the Smoke and Carbon monoxide detectors were fully operational. -------------Continued on LIC809-C--------------- LPA recorded the following deficiencies:, the details of which are in the LIC809-D citations. Technical Assistance: 130 - Fit testing not completed and will be completed by November 15, 2021. Physical Plant/Environmental Safety - Type A: 87308(c) - Kitchen knives were not stored in a locked drawer. Food Service - Type B: 87555(b)(15) - Food not properly labelled in refrigerator and freezer. Disaster Preparedness - Type B: 1569.695(a)(2) - Did not have emergency water on hand. Disaster Preparedness - Type B: 1569.695(a)(7)(A) - Generator located at another facility. Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.