Routine inspection·October 6, 2022

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Back-up Administrator, Michelle Gregorio and Licensee/Administrator, Arlinda Gregorio arrived later. 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 filling out a standard Covid-19 questionnaire. LPA initiated a walk-through of the facility around 9:20 am 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. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day and after use. Facility maintains documentation of staff and resident daily temperatures. 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. LPA and Licensee discussed visitation and activities. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. 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. Fire extinguishers were last serviced September 2022. Facility has a fire vendor that tests and services the fire system. The most recent service was conducted September 2022. The most recent inspection by the local fire department was conducted July, 2022. Carbon Monoxide detector was tested and operational. Continued on LIC809C Continued from LIC809C Licensee and LPA discussed their Emergency Disaster Plan and Infection Control Plan. Licensee/Administrator to submit updates of the following documents by 11/06/2022: LIC 308 Designated Administrator LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (review and update if changes) No deficiencies cited during this inspection.