Routine inspection·January 28, 2022

Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced, to conduct an Annual Required inspection and met with Staff Member Mary-Jane Miranda. Administrator Evelyn Chan was available by phone. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPAs observed that the facility had Covid-19 posters on the front door and a sanitation station. Sign directed visitors to sanitize prior to coming into the facility and notified them of current CCL guidance on visitation. Once inside, LPAs was screened by staff who checked LPAs' temperatures. Facility maintains a temperature log for visitors. LPAs conducted a walk-through of the facility and observed Covid-19 signs and hand sanitizer throughout. Per staff, staff and residents are screened daily and documentation is maintained. LPAs discussed infection control with staff. Staff are required to wear masks while in the facility and LPAs observed staff with mask on during this visit. Commonly touched surfaces are disinfected at least once per day, and as needed. LPAs confirmed that facility is following the staff vaccination guidance per PIN 21-44-ASC. Visitors are required to wear a mask while visiting the facility. Facility has submitted their Covid Mitigation Plan and it has been reviewed by CCL. Facility has a 30 day supply of Personal Protective Equipment (PPE) . Facility maintains a 30 day supply of medication. Caregivers have completed PPE training but have not been N-95 Fit tested. Staff and LPAs discussed their Emergency Disaster Plan. Fire extinguishers were last serviced February 2021. Carbon Monoxide Detector and smoke detector in hallway were tested. Smoke alarm was functional but Carbon Monoxide detector was not functioning correctly. A new detector was ordered during visit.. No deficiencies cited during this inspection.