Routine inspection·September 24, 2021

Licensing Program Analyst (LPA) Cuadra arrived unannounced, to conduct an Annual Required inspection and was greeted by Licensee, Emma Mutunga. The inspection is focused on the Infection Control procedures and practices of this facility. LPA conducted risk assessment call with Licensee prior to make a visit. Upon arrival, LPA observed that facility has Covid19 related posters on the front door indicating visitors about facility protocols. Once inside the facility, LPA observed that facility does have a sign-in for visitors and did screen LPA when they came in. Facility performs daily screening to residents and staff prior to come to work their shift. LPA observed that staff were wearing masks during this visit. Residents are encouraged to wear masks when in the community. 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 is kept in the common area of the facility but not throughout due to safety concerns. Facility has multiple bathrooms that are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected throughout the day. LPA discussed visitation with staff who stated that residents mostly receive essential visits and facility has a designated outdoor visit area with chairs and table available for residents to receive visitors outside. In case that a resident needs to be isolated/quarantine facility will provide a place outside of the facility and will ensure to provide care and supervision at all times. 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 residents are vaccinated and except for one staff who has not receive the vaccine yet. Facility has submitted their Covid Mitigation Plan and approved on 3/19/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer that are accessible for staff if needed. LPA confirmed that Licensee has reviewed updated PINs to ensure compliance with updated guidelines. LPA provided the following guidance: -Get staff N-95 fit tested. No deficiencies cited during this inspection.