Routine inspection·May 27, 2022

On 05/27/22 at 9:00AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with staff member Ritchie Castro upon entry and toured facility with LPA inside and out. Facility has a COVID-19 mitigation plan in place dated 03/01/21 that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were not posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing for which they were cited. All staff and clients have been fully vaccinated. The LPA and the staff member discussed the infection control plan from the PIN 22-13-ASC that will need to be created for the 06/30/22 due date. . A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 73.0 degrees and in the safe range. The hot water, however, was 140 degrees, which is far outside of the safe range of 105 to 120 degree Fahrenheit. Toxic chemicals were stored in locked closets and cabinets. However, sharp objects were not, again a Type A deficiency for which they were cited. Continued on next page LIC 809-C Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged and purchased in June of 2021. Cited for the Smoke and Carbon monoxide detectors that were not operational. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 06/03/22: · LIC500 - Personnel Report · LIC308 - Designation of Facility Responsibility · LIC610E - Emergency/Disaster Plan · Evidence of Liability Insurance & Surety Bond Facility cited for 2 Type A and 3 Type B deficiencies during this visit. Exit interview conducted and a copy of this report provided via email.