Routine inspection·June 15, 2021

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and was greeted by staff. Administrator, Nick Aquino arrived later. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA observed that facility has posters on the front door indicating that visitors are not allowed. Once inside the facility, LPA observed that facility does not have a sign-in for visitors and did not screen LPA when they came in. LPA observed that live-in staff were not wearing masks and LPA requested that staff put on masks. LPA conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility. Residents are encouraged to wear masks when in the community. Commonly touched surfaces are disinfected throughout the day. LPA discussed visitation with staff who stated that residents only receive visits from their case workers and there is a designated living room for visitation. Facility has a designated isolation apartment on the facility premises. Facility staff have been trained on PPE protocols but have not yet been N-95 fit tested. Facility has submitted their Covid Mitigation Plan and LPA reviewed it during this visit Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is in a location that is accessible to staff and additional PPE is available as needed but is stored off-site. Facility maintains a 30 day supply of medication. Continued on LIC809C Continued from LIC809 Facility has a 100% vaccination rate of staff and residents so is not required to surveillance test. LPA provided the following guidance: Review PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, ect and update visitation policy accordingly. Screen all visitors who come to the facility and have them sign-in to ensure proper tracing Get staff N-95 fit tested Staff to wear masks when in general areas of the facility Administrator and LPA discussed the Emergency Disaster Plan and LPA requested an updated Emergency Disaster Plan. No deficiencies cited during this inspection.