Routine inspection·September 17, 2021

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Staff, Gigi Borja and Licensee Keith Fletcher. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA observed that the facility has a sign on the door notifying visitors that they will be screened. LPA was asked to sign in and temperature was taken and documented. LPA conducted a walk-through of the facility and observed the following: Facility has Covid-19 posters throughout including but not limited to hand washing and cough etiquette. Facility was a comfortable temperature and exits were free from obstructions. Infection control is discussed with residents and staff. Residents receive assistance with hand washing. Residents are encouraged to wear masks when in the community and staff are required to wear them while in the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. LPA and staff discussed resident activities and visitation. There is a designated outdoor area for visitation. Visitors may also visit inside of the facility but are required to wear a mask and are screened. Facility to review PIN 21-40-ASC regarding visitation, testing and vaccination verification guidance for visitors. Caregivers have completed PPE training and have been N-95 Fit tested. Facility has submitted their Covid Mitigation Plan and it has been reviewed. 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. PPE is located in an area that is accessible to staff who need it. Facility maintains a 30 day supply of medication. Staff nd LPA discussed their Emergency Disaster Plan. No deficiencies cited during this inspection.