Routine inspection·July 26, 2022

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Griselda T. Garcia and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Griselda T. Garcias, who LPA Colvin found to be successfully incorporating the several aspects of COVID-19 best practices. LPA Colvin confirmed with Administrator that the facility did not current ahve a Mitigation Plan or an Infection Control Plan. LPA Colvin will be issuing the facility a Technical Advisory Note instead of a deficiency, as the Administrator is currently working on submission and completion of the Infection Control Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the Administrator's office, and LPA Colvin observed the facility to have a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Administrator Griselda T. Garcia in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Griselda T. Garcia informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. LPA Colvin will be providing Administrator with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened for symptoms prior to entering the facility. Other: Reporting Requirements - LPA Colvin reviewed Community Care Licensing's data storage software and did not observe any notes for a COVID outbreak at the facility in June 2022. LPA Colvin asked the Administrator about how it was reported, and the Administrator stated they left a voicemail on the main line for Licensing, but did not receive a call back. LPA Colvin inquired as to if there was any additional reporting to Licensing, such as a Special Incident Report (SIR). Administrator Griselda T. Garcia stated that no such subsequent reports were made by herself (as she was out with COVID-19) or by other staff. Deficiency cited. Licensing Fees - Prior to coming out to the facility, LPA Colvin pulled the facility's history for Licensing fees, and observed that the facility was past due for the annual fee for 2022 in the amount of $1,238.00. Deficiency cited. Criminal Background Clearance - During LPA Colvin's inspection, LPA Colvin observed that Administrator Griselda T. Garcia was not on the facility's staff roster, which LPA Colvin had pulled from Guardian this morning. LPA Colvin additionally contacted Licensing Office staff to have them double check the Administrator's clearance status, and confirmed that while Griselda T. Garcia is cleared, she is not associated to the facility. LPA Colvin reviewed the Administrator's file at the facility and observed a request for Clearance transfer as well as additional documents that would be required to update the Administrator on file. The Administrator additionally had a copy of a receipt for mailing the documents out. LPA Colvin will not be citing a deficiency or issuing civil penalties as the Administrator submitted the documents as required, and they most likely have just not been processed yet. An exit interview was conducted with Administrator Griselda T. Garcia and a copy of this report, LIC809D, and appeal rights were provided.