Routine inspection·November 2, 2021

Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. LPA was greeted by caregivers Fleming Nkonjera and Mombolwa, who allowed LPA to enter the facility. Upon entering the facility, there routine symptom screening in place at the front door. Everyone was informed the reason of the visit. Administrator Tina Keshishian was notified and arrived shortly after. Administrator reported to LPA, that there have not been any active or past COVID cases at the facility. There current census is (5), and staff and residents have been vaccinated. LPA observed Licensing COVID-19 posting inside the facility at the front door entrance, and throughout the facility. The infection control inspection was conducted throughout the facility with the caregivers. The facility has (4) bedrooms; with (2) shared and (2) private rooms. 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, bathrooms and resident rooms. LPA conducted a mitigation plan review with the Administrator, to obtain information how the facility has implemented the plan. According to the latest documentation of the facility's mitigation plan, it was reported that the Administrator submitted an incomplete report. Administrator reported to LPA that the plan was submitted to previous LPA Gary Tan. LPA requested a copy and the Administrator emailed to LPA during the visit. LPA reviewed the report and requested some additional information. Administrator will correct and submit to LPA. The facility is not currently conducting COVID-19 surveillance testing; but will begin to implement a plan for staff. Daily temperature for residents and staff are performed daily. 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. The facility had sufficient staff and Administrator recently hired additional staff. 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 the beginning of the pandemic. The facility is aware to report any changes with residents or staff to Licensing pertaining to positive COVID-19 cases. Exit interview and copy of report provided to Administrator.