Routine inspection·April 25, 2022

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and was greeted by staff. Administrator, Nick Aquino arrived later but had to leave prior to the end of the inspection and gave permission for staff to sign report. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA was screened by staff including having their temperature checked and filling out a questionnaire with standard Covid-19 symptom questions.. Visitors are screened and vaccination verification is being conducted per Provider Information Notice (PIN) 22-07-ASC . 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. LPA request that hand washing signs are put up in the client bathrooms and a visitor poster that is inside the facility is put on the front door. 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 at least once per 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. LPA discussed options with Administrator for having their staff N-95 fit tested. Facility has submitted their Covid Mitigation Plan and it has been reviewed Facility has 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 submitted and Community Care Licensing (CCL) has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced June 2021. During inspection LPA observed that the facility is having a deck put in in the backyard and a new fence is being put up. Construction area is roped off with caution tape. Administrator to ensure that staff receive continued training regarding Covid-19 including but not limited to infection control and PPE donning and doffing. Administrator and LPA discussed their Emergency Disaster Plan and the new Infection Control Plan that all facilities must submit to CCL by June 30, 2022. Administrator to submit updates of the following document by 05/25/2022: LIC 308 Designated Administrator LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Liability Insurance No deficiencies cited during this inspection.