Routine inspection·October 4, 2022

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced annual while at the facility for a separate visit. LPA met with Aaron Lazarus, Administrator, who was informed of the purpose of the visit. LPA observed (2) staff members and (5) residents at the time of the visit. LPA conducted a walk-through the the interior and exterior of the facility. LPA observed the facility to have (5) bedrooms and (3) bathrooms. The facility has a laundry room, basement, and outdoor area. LPA observed the resident rooms where residents would be isolating in case of COVID-19. LPA observed the facility to have adequate hand hygiene supplies, and 30-day supply of PPE equipment. Administrator informed LPA on staff leave, staff procedures when testing positive for COVID-19, and staffing plan in case of shortages. LPA observed one central entry point where symptoms screening and sign in sheet are being kept. LPA observed COVID-19 posting throughout the facility. The staff are trained on how to properly use PPE and have been N95 FIT tested. LPA reviewed the facility roster and found that all staff have been associated and fingerprint cleared. LPA observed the facilities paper supplies, and food supply while at the facility. LPA observed where the facility is keeping the sharp objects and medications locked in a hallway cabinet by the kitchen. LPA observed seating areas both indoors and outdoors. LPA observed a locked gate on facility kitchen access point. LPA asked Administrator if the facility had a waiver or exception for this gate, who stated there was none. Administrator stated he was not aware a waiver or exception was needed for a gate. LPA will cite deficiency and document plan of correction for this gate. An exit interview was conducted where this report, LIC809-D, and appeal rights were reviewed with Administrator Aaron Lazarus.