Routine inspection·June 10, 2021

Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 6/10/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Rosalie Gomez (Designated Administrator) and explained the purpose of the visit. Upon arrival at facility, staff contacted admin to speak with LPA. Admin informed LPA that Rosalie can sign documents in lieu of Admin’s Absence. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by Rosalie Gomez. LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) of five (5) resident bedrooms, staff bedroom, three (3) of three (3) bathrooms, kitchen, and yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and staff completed the infection control domain and facility was found to be in compliance at this time. LPA is to send administrator additional documentation regarding Fit Testing and Donning and Doffing. LPA is requesting the following documents from Administrator to be submitted to Community Care Licensing (CCL) by COB 6/18/2021: Personnel Report (LIC 500); Designation of Administrator Responsibility (LIC309) current Administrator Certificate; Neighborhood Complaint Procedure (B-15). No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.