Routine inspection·March 7, 2023

Licensing Program Analyst's (LPA's) De Leon and Kontilis conducted a 1 year Annual visit to the facility above. LPA's met with Gary Gleissner, Licensee and explained the purpose of the visit. LPA's took a physical plant tour of the facility with Licensee. The Facility has submitted a mitigation plan and Emergency Disaster Plan to the department. The facility has not submitted an infection control plan to the department. The facility has a central entry point to sign in and symptom screen. Routine symptom screening is being conducted on all client in care and anyone showing any signs or symptoms is isolated and tested. Signs are posted at entrance and in the common areas of the facility regarding Covid-19. Hand Sanitizer is available at entry, every room, and the facility has 5 resident bedrooms and 2 resident rest-rooms with plenty of soap, paper towels, toilet paper, and hand washing signs. Trash bins have covers. Facility has 30+ days of PPE supplies. Facility staff wear masks at the facility and when on outings with clients. Facility staff will wear full PPE with N95 masks with face shields when dealing with any pending or confirmed cases of Covid-19. Facility will keep track of staff vaccinations. Facility staff have non-punitive sick leave policies and sick staff are requested to stay home and not report to work if they are ill. Facility has developed policies for Covid-19 precautions. PPE supplies are stored in storage areas accessible to staff working. Facility audits all supplies and replenishes when low. Administrator has a plan in place for back-up staffing when and if needed. All residents in care have the right to reject medical services. The facility keeps staff on duty who is trained and competent to handle and deal with emergency personnel. Continued 809-C The facility has an emergency plan which was not posted. Residents records were reviewed and all 5 residents in care are missing required forms. 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. Smoke and carbon monoxide detectors are present in the facility they are dual and hard wired. The facility did not have self closing and self latching gates as required by regulation. The kitchen oven, stove, and grease around the area needs to be cleaned. The showers do not have non slip mats. Cleaning products were not locked and some were left in areas accessible to residents. LPA Kontilis tested water in resident rest-rooms temperature was 117.5 F. Fire extinguishers were charged but had not been inspected since 11/20/2019 or none of them had a receipt attached for proof of purchase within 1 year. LPA's will return at a later date to complete the annual inspection to review remaining resident files, staff files, training records and to conduct interviews as well as follow up on technical violations issued on today's visit. Exit interview completed, technical violations issued and copy of report printed for Administrator.