Routine inspection·October 26, 2021

At 3:25 pm, on 10/26/2021, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced annual infection control inspection of the facility above. LPA informed caregivers Elsa Gebretensae and Rebecca Griffin of the reason for the visit. Administrator Abiy Tesfazgy was not at the facility and arrived at approximately 4:15 pm. LPA and Ms. Gebretensae toured the facility. LPA’s initial tour of the facility resulted in observations which were immediately addressed by the administrator and facility staff: At 3:25 pm, LPA requested the facility screen LPA for COVID-19 upon entry to facility which was immediately conducted. At 3:27 pm, LPA observed that the sign-in sheet did not have temperatures recorded, and staff immediately added a column to record temperatures. At 4:00 pm, LPA noticed Provider Information Notices (PINs) or PIN summaries were not posted in the facility, and staff post them immediately. At 4:15 pm, staff said they have not been fit tested for N95 respirators. Administrator stated he will get fit tested and train staff by 11/03/21. At 4:32 pm, the current 8.5"x11" complaint poster was observed, and administrator will post a 20"x26" immediately. At 4:00 pm, LPA conducted the Infection Control mitigation module with Caregiver Rebecca Griffin until Administrator Tesfazgy arrived. No deficiencies noted. Exit interview conducted and report emailed to administrator.