Routine inspection·May 4, 2022

On 05/04/2022 at 1:00PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with Administrator upon entry. Infection control designated leader is the administrator. Facility has a COVID-19 mitigation plan (LIC 808) in place dated 09/27/2021. LPA discussed the importance of having an updated infection control plan in accordance with PIN 22-13-ASC . LPA inspected the facility inside and outside. LPA observed staff interacting with the client. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log. However, staff and resident were not wearing face mask, nor were and face masks or no touch thermometer at the entry point. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read, but it is outdated. There were at least 7 days of nonperishable and 2 days of perishable foods on hand. Medications were centrally stored in a locked cabinet. Sharp objects were stored in a locked cabinet and toxic chemicals were stored in a locked cabinet inside of the garage.. Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fully functioning carbon monoxide and smoke detectors. Fire extinguishers were fully charged. All staff and client have been fully vaccinated. Adequate supplies of PPE were also observed stored on the premises. Facility follows daily cleaning and sanitation procedures on frequently touched common surfaces with disinfectants. Continued on next page LIC 809-C Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/11/2022: · LIC500 - Personnel Report · LIC308 - Designation of Facility Responsibility · LIC610D - Emergency/Disaster Plan · LIC999 - Facility Yard Sketch with Emergency Meeting Location Added · Evidence of Liability Insurance & Surety Bond Facility cited with 4 Type B deficiencies. Exit interview conducted and a copy of this report provided via email.