Routine inspection·May 26, 2022

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Victor Dada. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA rang the doorbell at the gate multiple times and called the Licensee. LPA waited for approximately thirty minutes until Licensee answered the phone. LPA discussed concerns with Licensee regarding wait times, specifically if residents were able to alert staff if they needed assistance during the night. LPA confirmed that the doorbell on the gate does work and the alert goes to the Licensee's phone. LPA suggested turning up the phone or using a different device. Caregiver showed LPA the motion detector that is used in the resident's room in case they get up in the night and is loud enough to alert staff. LPA observed Covid posters on the front door. Once inside, LPA observed a screening station near the entrance along with a visitor sign in. LPA confirmed with caregiver that they are screening all visitors. Facility is not currently conducting vaccine verification noting that there is only one person who visits. LPA directed caregiver to verify vaccination status of all visitors per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility at around 8:55 am and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected once per day. Continued on LIC809C Continued from LIC809 Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff have conducted PPE training but have not been N95 fit tested. LPA and Licensee discussed visitation and activities. 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 not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Facility has hardwired combination smoke and carbon monoxide detectors throughout facility that were tested and operational. Fire extinguishers were last serviced April 2022. Licensee and LPA discussed their Emergency Disaster Plan as well as the Infection Control Plan (PIN 22-13) that is due June 30, 2022. Licensee/Administrator to submit updates of the following documents by 6/26/2022: LIC 308 Designated Administrator LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Residents Liability Insurance No deficiencies cited during this inspection.