Routine inspection·May 20, 2022

Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 05/20/2022 at 11:45 AM. LPA met with Staff Nayrani Mendoza and explained the purpose of the visit. LPA took a physical plant tour of the facility. 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, symptom questionnaire and temperature screening. All documentation is kept on a clipboard and in binders. The entry station has hand sanitizer along with a thermometer and additional PPE if needed. The facility has a large activity room, a dining room for dining, and a living area, all areas are spaced to accommodate as much space as possible for social distancing. The facility has a large covered patio for resident use. All additional equipment and PPE supplies are kept in the staff office. Medications are kept in a locked medication cabinet in kitchen pantry. 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 are noted or any residents are showing any signs, symptoms or have a temperature. 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 have 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 working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Continued 809-C Emergency Disaster plan is posted but is not up to date, last updated LIC 610E (10/03) signed and dated 10/01/2015, this form is required to be up to date and a new form has been released by the department. House Manager is in charge of infection control and provides training and education to staff, residents and visitors. House Manager 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 individuals and will not work with other negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 4 resident bedrooms and 2 resident bathrooms and they are disinfected after use. Precautionary Droplet 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 has a plan in place for when and whom to notify in an outbreak or other emergencies. House Manager 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 cabinets in the staff office. 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. The facility is in a current outbreak and staff do not have N95 fit testing certifications. Administrator on record is not currently the administrator of the home and no staff have a valid administrators certificate or designee form on file. Fire extinguishers are charged and inspected annually. Exit interview completed, deficiencies cited, copy of report and appeal rights emailed to Administrator/Licensee.