Routine inspection·July 30, 2021

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced annual required licensing inspection. After identifying themselves and disclosing the purpose of the visit, LPA was granted entry by Administrator Maria Richley. An inspection tour was conducted inside and out, including verifying compliance with statutes, regulations and other written requirements that are relevant to protecting the health of residents in care and staff, including in the area of infection control practices. LPA assessed the strategies the facility is employing for the prevention, containment and mitigation of COVID-19, including the implementation of infection control guidance, staff retention and essential health and safety. The Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) was reviewed with Maria, including: Residents in Care, Staff, Visitors, Facilities without COVID-19, Infection Control and Physical Distancing. LPA observed one central entry point for universal entry, a sign-in policy and symptom screening initiated at entry for all staff, visitors and residents; the facility’s visitor policy posted at the entrance, signs throughout the facility promoting hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and face coverings recommended to residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit. An exit interview was conducted with Maria and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) was provided to them via email; an email read receipt confirms receipt of these rights.