Routine inspection·September 21, 2022

On 9/21/22 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit to staff and conducted the initial inspection inside and outside of the facility. Administrators Raquel Coyle and Flor Reyes arrived later and together they discussed the LPA's findings and any deficiencies identified during the inspection. Facility has an infection control plan in place that they are following. The administrators are the designated infection control leaders. 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 thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. Facility had signs posted to promote hand washing and mask wearing. The fire extinguisher has been serviced within the past 12 months, The carbon monoxide and smoke detectors were fully functional. The temperature inside of the facility was 69.8 and the hot water was 112 degrees, both in the safe temperature range. An administrator is on site at least the required 20 hour minimum each week to oversee business operations. Facility cited for 3 Type B deficiencies due to non-regulation medicine dispensing practices, not conducting quarterly emergency drills, and converting a shed into a bedroom that was being used by a staff member (refer to LIC 809-D). Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email.