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25 | On 05/02/24 at 1:55PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with S1 and ADM.
At 2:20PM LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in storage cabinets. Comfortable temperature is maintained at 74 deg F. Hot water temperature was measured at 111 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged and last inspected on 04/12/24. LPA reviewed 5 staff and 5 resident files. LPA also conducted 2 staff and 2 resident interviews during visit.
Updated copies of the following documents were obtained for facility file:
LIC500- Personnel Report
Resident Roster
LIC308- Designation of Facility Responsibility
LIC610E- Emergency/Disaster Plan including infection control plans
Evidence of Liability Insurance
No deficiencies cited during visit. Exit interview conducted and a copy of this report provided. |