Routine inspection·April 8, 2022

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/8/22 to conduct a Annual Inspection utilizing the infection control domain guidance. LPA met with Hazel Estante and explained the purpose of the visit. Prior to initiating the inspection, LPA completed required COVID-19 safety protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Hazel upon entering the facility. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Hazel covered the infection control topics and facility was found to be in substantial compliance at this time. Facility is currently using HCA staffing at times. LPA advised: maintaining record of staff vaccination status and weekly testing of those not fully vaccinated to be maintained at the facility, double check on guardian that staff fingerprinted are associated to the facility (including agency staff who work independently with residents), Visitation sign be posted outside the front door, barrel was moved to allow unobstructed exit from side yard, insulin was secured while LPA present, develop a system that allows staff administering medication to know the medication and dose dispensed, secure cleaning supplies in the laundry room. LPA requested Administrator submit: Resident roster, staff roster, proof of liability insurance, emergency and disaster plan to CCL by 4/14/22. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.