Routine inspection·June 22, 2021

Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility 945am to conduct an unannounced infection control inspection/visit. LPA was greeted by caregiver Dennis Bonifacio, who allowed LPA to enter the facility. LPA observed residents eating breakfast and watching television in the living room. Upon entering the facility, there routine symptom screening was not initiated or conducted by the caregiver, and LPA was not requested to sign in the visitor’s book. Administrator Florence Peregrino was present, and LPA informed her the reason of the visit, and staff did not check temperature or request LPA to sign in the visitor's book. Administrator stated, she was not at the front door. LPA informed Administrator that all staff should be checking temperatures when individuals enter there facility. There have not been any active or past COVID cases at the facility since January 2021. There current census is (6), and all staff and residents have been vaccinated. LPA observed hand sanitizing station, and visitor sign in book at the front door. LPA observed Licensing COVID-19 posting inside the facility at the front door entrance, but no signs were posted outside. LPA informed Administrator, that signs should be posted outside of the facility, and there needs to be more signs posted throughout the facility. Administrator informed LPA, that she would post more signs. The infection control inspection was conducted throughout the facility with the Administrator. The facility has (6) bedrooms; with (1) shared room and beds were kept (6) feet apart. All common areas were observed to be clean, including bathrooms, that had soap and towels. There were hand washing signs observed at the kitchen sink and all bathrooms. LPA conducted a mitigation plan review with the Administrator, to obtain information on how the facility has implemented the plan. Administrator reported they no longer conduct COVID-19 surveillance testing, since everyone has been vaccinated. Daily temperature for residents is performed daily, and LPA observed documentation. Visitation is conducted outside on the backyard patio. Residents eat together and practice social distancing at the dining room table. Administrator informed LPA, she received the PINs from the department, and conducts training to staff in relation to COVID-19. There are designated rooms for potential positive COVID residents. PPE, chemicals, cleaning supplies, and paper products were observed, with a viable supply. LPA observed the facility has Licensing requirement for food supply. During the visit, the facility had sufficient staff; but LPA does have concerns, due to the number of residents that are bedridden and non-ambulatory. LPA had a discussion with the Administrator, who stated, she has back-up staff if needed. The facility has not had any positive COVID-19 reports for staff or residents. Administrator informed LPA that they continue to implement the best practices for their facility; which has kept them COVID-19 free since there first outbreak in January 2021. Staff have been trained and notified regarding sick and return to work policies. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases. Exit interview and technical assistance (TA) violation was discussed with Administrator. Report signed during visit.