Routine inspection·April 14, 2022

Licensing Program Analyst (LPA) Esther Miller conducted an unannounced annual required inspection on today's date. LPA was greeted at the front door and granted entry by Teresita Roxas, Licensee, after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. LPA reviewed with Licensee the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC808) including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility Plans for Infection Control, and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings were worn by staff under their chin after being reminded to place masks on correctly; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is mostly in compliance with and has implemented infection control practices as outlined in its LIC808. During today's visit, a technical assistance was given to Licensee for staff mask wearing. An exit interview was conducted with Licensee, and a copy of this report along with Licensee/Appeal Rights (LIC9058 FAS 01/16) was provided via email; facility representative expressed that they would send LPA a confirmation email upon receipt of these documents.