Routine inspection·May 28, 2021

Licensing Program Analyst (LPA) A. Canela arrived unannounced to conduct an Annual Required inspection and met with Backup Administrator, Aileen Bryant. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA observed that facility has a table just inside of the entrance to the facility with hand sanitizer, masks and a thermometer. Staff screened LPA and requested LPA to sign in. Per conversation with Administrator, they check the temperature of visitors and asks them screening questions. LPA conducted a walk-through of the facility with the administrator and observed Covid-19 posters throughout the facility that includes hand washing and directions to cover coughs. LPA asked if 25% of staff are surveillance testing weekly and administrator stated they weren't because everyone is vaccinated. LPA observed four clients in the home. Facility staff have completed PPE training but have not yet been N-95 Fit tested. Facility is disinfected throughout the day. Facility has submitted and received approval for a Covid Mitigation plan. Facility has a 30 day supply of PPE and medication. Most clients do not typically wear masks inside the facility but staff do encourage mask wearing when outside of the facility. Staff had masks on during this visit. Staff have discussed with clients the importance of mask wearing and social distancing while in the community. LPA provided the following guidance to staff: Continue surveillance testing for staff regardless of vaccination status Complete N-95 Fit Testing for all staff Review PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, ect. No deficiencies cited during this inspection