Routine inspection·June 17, 2021

Licensing Program Analysts (LPA) Victoria Willis and Erik Gonzalez Campos arrived unannounced, to conduct an annual required inspection and were greeted by staff. Administrator, Josephine Credo arrived later. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPAs were screened by staff and screening was documented. LPAs initiated walk-through of the facility with administrator at 11:00 and observed COVID-19 posters throughout that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Infection control has been discussed with residents and staff. Hand sanitizer is located centrally for client and staff use. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected on each shift. Facility had a recent fire inspection on April 27, 2021. No smoke alarm issues were noted. Common areas are set up for social distancing. Facility has a designated visitation area. Staff have completed PPE training and have been N95 fit tested. Facility has submitted and received approval for their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. Facility maintains a 30 day supply of medication. Facility has over 70 percent vaccination rate of staff and residents so may discontinue surveillance testing. According to Administrator, they have reviewed PINs 21-17-ASC and 21-17.1-ASC for new guidance regarding visitation, communal dining, etc. Administrator and LPAs discussed their Emergency Disaster Plan. No deficiencies cited during this inspection.