Routine inspection·August 4, 2023

On 08/04/23 at 12:45PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (manager on duty (MOD) and Resident Care Director (RCD) and explained the purpose of the visit. LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 75 deg F. Hot water temperature was measured at 111.3 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 10/10/2022. LPA observed facility to be clean and in good repair. LPA reviewed 5 staff and 5 resident files. LPA also conducted 5 staff and 5 resident interviews during visit. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 08/07/23:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided .