Routine inspection·November 18, 2021

Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator, Licensee, and Infection Control Leader Rachelle Santiago. LPA observed 3 staff wearing face masks during visit. Facility has a completed COVID-19 mitigation plan (LIC 808) in place dated 03/12/2021. LPA discussed the LIC 808 with administrator and reviewed up-to-date COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check is done at entry for all staff, residents, and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Ms. Santiago has conducted staff training on infection prevention, symptoms, transmission and proper donning and doffing of PPE. All staff and residents are fully vaccinated. There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper & PPE supplies were observed stored in the facility. Facility room temperature was maintained at a comfortable level and the hot water temperature was within the safe 105 to 120 degree range. A certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged and Smoke and Carbon monoxide detectors were operational. Though pathways were free of obstruction and fire hazards, there was junk in the back yard and physical plant repairs needed that were cited as Type B. Exit interview conducted and a copy of this report was provided to the administrator.