Routine inspection·May 17, 2022

On 05/17/22 at 12:15PM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with S1 and S2 upon entry who assisted in the tour of the facility inside and outside until Administrator Olubunmi "Anthony" Oshinowo arrived at approximately 1:00PM. Facility has a COVID-19 mitigation plan in place dated 03/03/21 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. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. All staff and clients have been fully vaccinated. The LPA and Administrator discussed the infection control plan from the PIN 22-13-ASC that will need to be created for the 06/30/22 due date. However, they were issued a citation for not having the required 30 day supply of PPE. Continued on next page LIC 809-C A written Emergency/Disaster plan completed in 2019 was posted on the bulletin board for staff, clients and visitors to read. Centrally stored medications were in locked cabinets adjacent to the kitchen. The temperature inside of the facility was 81.3 degrees and the hot water was 110 degrees, both within the safe range. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were stored in a locked closets and cabinets. Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged and the Smoke and Carbon monoxide detectors were operational. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/24/22: · LIC500 - Personnel Report · LIC308 - Designation of Facility Responsibility · LIC610E - Emergency/Disaster Plan (update if needed) · Evidence of Liability Insurance & Surety Bond Facility cited with 3 Type B deficiencies: Exit interview conducted and a copy of this report provided via email.