Routine inspection·September 1, 2022

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Brisa Junco. The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry into the facility, LPA observed Covid-19 posters above the screening station. The screening station had masks, hand sanitizer and a thermometer along with a book for visitors to sign in. LPA confirmed with Licensee that staff are screening visitors and conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. Per Licensee, they do encourage outside visitation but allow for inside visitation per CCL Guidance. LPA initiated a walk-through of the facility around 1:30 pm and observed the following: Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility and resident rooms. Observed staff had masks on during this visit. Per Licensee, commonly touched surfaces are disinfected twice per shift. Staff continue to receive training per the facility's Infection Control Plan and have been N95 fit tested. LPA and Licensee discussed visitation and activities. Facility maintains documentation of staff and resident temperatures. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but to limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced May 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational. Continued on LIC809C Continued from LIC809 Licensee and LPA discussed their Emergency Disaster Plan and their Infection Control Plan. Licensee to submit updates of the following documents by 10/01/2022 LIC 308 Designated Administrator (if applicable) LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if any changes) LIC 9020 Register of Facility Client’s/Resident’s Copy of Liability Insurance No deficiencies cited during this inspection.