Routine inspection·August 30, 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 caregiver Vincent Cabauatan 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 caregiver Vincent Cabauatan, who LPA Colvin found to be successfully incorporating the several aspects of the infection control, despite not having a Mitigation Plan on file. LPA Colvin inquired about if there was a copy at the facility for LPA Colvin to review (as there is no evidence that one has been submitted to Licensing) and the caregiver Vincent Cabauatan stated that there is not. LPA Colvin will be issuing a Technical Advisory Note for the facility not having a Mitigation Plan. LPA Colvin will not be issuing a deficiency as the Mitigation Plan request/requirement is outdated, and facilities are now being advised to submit an Infection Control Plan. 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). LPA Colvin observed the facility to not have an adequate supply of PPE, and caregiver Vincent Cabauatan was unaware of where additional PPE might be located. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note for the facility not having a 30-day supply of PPE. LPA Colvin went over the various recommended training for facility staff with caregiver Vincent Cabauatan 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 caregiver Vincent Cabauatan informed LPA Colvin that they have. LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. caregiver Vincent Cabauatan confirmed that residents are being screened daily. 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, as LPA Colvin was today. LPA Colvin additionally confirmed that all facility staff are vaccinated, so the facility is not required to continue with surveillance testing weekly, and caregiver Vincent Cabauatan confirmed that both new staff and new residents must present a negative COVID-19 test prior to start of employment or residence at the facility. Other: During LPA Colvin's inspection, LPA Colvin observed that Vincent Cabauatan and his wife Ingrid were both not on the facility's employee roster, or associated to the facility. LPA Colvin contacted two staff back at the Licensing Office to double and triple check, and both staff confirmed that while both Cabauatans have background clearance, neither is associated to any facility. LPA Colvin inquired with Vincent Cabauatan as to how long he and his wife have been working at the facility. Vincent Cabauatan claimed that today was his and his wife's first day, though they have worked here previously. LPA Colvin attempted to contact the Administrator to verify employment start date, but was unable to reach them. LPA Colvin will be citing a deficiency and issuing civil penalties in the amount of $100 per staff for one day working at the facility, for a total of $200 . LPA Colvin will additionally be issuing a deficiency for not being able to access staff files. An exit interview was conducted with caregiver Vincent Cabauatan and a copy of this report, LIC809D, LIC421BG, appeal rights, and LIC9102 TA Advisory Notes were provided.