Routine inspection·August 3, 2021

Licensing Program Analyst (LPA) Cuadra arrived unannounced, to conduct an Annual Required inspection and was greeted by Administrator, Charito Santos. 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 have a sign-in for visitors and did screen LPA when they came in. LPA observed that staff were wearing masks during this visit. 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. 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 they have chairs available for residents to receive visitors outside. 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 maintains a 30 day supply of medication. Facility has a 100% vaccination rate of staff, but 2 residents are not vaccinated. Residents are encouraged to wear masks when in the community. Facility has submitted their Covid Mitigation Plan and approved on 5/18/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer. LPA provided the following guidance: Review PINs 21-28-ASC and 21-32-ASC for new guidance regarding visitation, communal dining, etc. Get staff N-95 fit tested No deficiencies cited during this inspection.