Routine inspection·July 29, 2021

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with staff, Marilen Azur. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA was asked to sign in and was screened for Covid-19 symptoms. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout that included hand washing signs in restrooms and posters at entrances. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility. Per staff, clients are assisted with hand hygiene. Clients are not always able to tolerate wearing masks but staff are required to wear them while in the facility. LPA observed staff had masks on during this visit. Clients have their meals staggered at the the dining room table for social distancing. Common areas are also set up for social distancing. LPA and staff discussed client activities and visitation. Facility has a designated visiting area in the backyard. Caregivers have been provided PPE training. Facility has not yet had staff N-95 Fit tested. Commonly touched surfaces are disinfected throughout the day. Facility has submitted and the department has reviewed 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 had an inspection done July 12, 2021 of their fire alarm system. 100% of clients and staff are vaccinated. Per PIN, facility may discontinue surveillance testing. LPA discussed the Emergency Disaster Plan with staff and confirmed that staff on all shifts are able to drive the facility van. LPA suggested that staff are trained on new Covid-19 guidance from the CDC. Current training materials are dated. No deficiencies cited during this inspection.