Routine inspection·October 17, 2022

Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 8:45 AM and utilized hand sanitizer. The LPA met with Co-Administrator, Joseph Ko, and informed him of the purpose of her visit. There are currently no cases of COVID-19 within the facility. During today's visit, the LPA toured the home and made observations pertaining to the facility's infection control measures. The LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and cleaning and disinfection provisions are in adequate quantities. The facility has a Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report in place and is pending review from the Department. The plan establishes guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor resident's regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. The following deficiencies were observed: no symptom screening for visitors, staff or residents; no daily temperature checks; no sign in policy in place; no signs indicating the visitor's policy; chairs in television room were not physically distanced; no 95 Fit testing; no sick leave training for staff; and insufficient Personal Protective Equipment (PPE). This poses a potential health, safety or personal rights risk to persons in care. An exit interview to review this report was conducted with Ko and a copy of this report was provided, along with appeal rights.