Routine inspection·January 12, 2023

Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 01/12/2023 at 1:20 PM. LPA met with Administrator Edwin Ingan and explained the purpose of the visit. LPA took a physical plant tour of the inside and outside of the facility with Administrator. The facility has submitted a mitigation plan to the department and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in and symptoms screening. All documentation is kept on a clipboard. The entry station has hand sanitizer along with a thermometer. The facility has a living room to accommodate activities, a dining room for dining, all areas are spaced to accommodate as much space as possible for social distancing. The facility has a table and chairs with umbrella for resident outside use. All equipment and PPE supplies are kept in the garage. Medications are kept in a locked medication cart in the dining area. The staff screen residents for symptoms and temperature 1x's a day and documentation is kept on file. Increased monitoring is conducted if any change of condition is noted. Signs are posted on the front door, entry area and walls in common areas regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before residing or working in the facility. Continued 809-C The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated. Staff will use full PPE with N95 masks along with a face shields when dealing with any pending or confirmed cases of Covid-19. The facility has 3 resident bedrooms and 2 resident bathrooms which are disinfected regularly. Enhanced precautions signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked closet. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificate is valid. Fire extinguisher is charged and inspected annually. Smoke alarms and Carbon monoxide detectors are present. No deficiencies observed during the visit and all infection control protocols are implemented and are being followed. Exit interview completed and copy of report emailed to Administrator.