Routine inspection·April 13, 2022

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 04/13/2022 at 09:55 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrators Maria and Livius Puraci 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 Brown went over COVID-19 best practices for infection control and prevention with Administrators Maria and Livius Puraci and they reported that Mitigation Plan was submitted to Community Care Licensing Department (CCLD). LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility and observed that resident bathrooms have paper towels and hand soap. At around 10:30 AM, LPA Brown observed two (2) knives with measurement 4.25 ft and 9.5 ft located in an unlocked drawer in the kitchen and LPA Brown also noticed that the lock of the knife drawer in the kitchen is broken making all knives at the facility accessible to residents in care. LPA Brown requested Staff 3 to lock all knives in a locked drawer during the visit. LPA Brown will be issuing a deficiency as this poses an immediate risk to residents in care. In addition, LPA Brown observed evidenced of water leak in the hallway ceiling from the front door going to the kitchen and Licensee Livius Puraci reported that it was the facility's air conditioning unit that caused the leak. LPA Brown will be issuing a deficiency as this poses a potential risk to residents in care. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, isolation gowns, face shields/goggles. LPA Brown went over the various recommended training for facility staff with Administrators Maria and Livius Puraci in relation to COVID-19 and they both reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. *** Continuation in LIC809C *** LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrators Maria and Livius Puraci informed LPA Brown that at this time staff have not been fit tested. LPA Brown will not be issuing a deficiency but Technical Assistance Advisory Notes will be issued during today's inspection for staff not being fit tested for N95 masks due to the facility not having COVID-19 positive staff and N95 masks needs to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, all residents and most staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown informed Administrators Puraci of the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents for COVID-19, when and how to isolate/quarantine resident, 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 their residents 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. During the visit, LPA Brown requested staff vaccination records and on 04/13/2022 at 10:45 AM, LPA Brown observed no vaccination record for Staff 3 and no exemption on staff file. Also, Staff 1 and Staff 2 do not have their booster information or booster exemption on file at the facility. LPA Brown will be issuing a deficiency for failure to keep records of Worker’s Vaccination which can pose potential risk to residents in care. Moreover, LPA Brown observed Administrator Livius Puraci not wearing mask during the visit and LPA Brown will be issuing a Technical Assistance Advisory Notes for staff not wearing mask. An exit interview was conducted with Administrators Maria and Luis Puraci and a copy of this report (LIC809), LIC 809-D's, LIC9102 AN Technical Assistance Advisory Notes and Appeal Rights were provided.