Routine inspection·February 23, 2023

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Manager staff Lot Santos. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and signing in. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least three times per day. Facility continues to screen staff and residents and maintains documentation. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Facility has submitted their Emergency Disaster Plan, Infection Control Plan and Mitigation Plan. Fire extinguisher is fully charged and serviced within the last year. Smoke detectors and carbon monoxide were tested and found operational. LPA was informed by Manager during the visit there is another certified Administrator Sheila Sumabat on duty as well. LPA discussed and requested the following documents to change Administrator on file. Administrator agreed to submit the following by 3/6/2023 : LIC215 Applicant Information, LIC 500 Personnel Summary, LIC 308 Designated Administrator, LIC 501 Personnel Record, Administrator Resume, Copy of current Administrator certificate, copy of Personal ID, Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations), LIC 610 Emergency Disaster Plan (review and update if changes), Liability Insurance and lease agreement. No deficiencies cited during this inspection.