The current census is 5 residents. 2 residents share Bedroom #2. 2 residents share Bedroom #3. Bedroom #4 is a private room. Bedroom #1 is vacant.

LPA Reed entered through the facility’s main entrance at the northwest corner of Beckford Avenue and Jovan Street. Administrator has designated this door as the facility’s main screening point for visitors and guests. Staff Maria Caballero answered the front door and explained the facility’s visitation procedures. Staff Maria explained how staff check for masks, take temperatures and screen for COVID-19 symptoms. Administrator showed LPA Reed the visitor log and COVID-19 symptom check log. Both logs are located on a table in the Family Room near Exit #3, as seen on the Facility Sketch. The table also has two bottles of hand sanitizer on top.

Staff did not take LPA’s temperature nor ask for COVID-19 symptoms. LPA Reed reminded Administrator to screen all guests to the facility.

At 11:23 AM, LPA Reed and Administrator conducted the facility tour inside and out.

LPA observed signs on the front door and main entrance area pertaining to COVID-19 precautions, masking requirements, proper coughing etiquette, and social distancing. LPA observed signs on the doors of Bedroom #1, Bathroom #1, Bedroom #2, Bathroom #2, Bedroom #3, in the kitchen, and in the hallway. The signs contained information for good health habits, droplet precautions, social distancing, proper cough etiquette, and handwashing instructions. LPA observed two beds in Bedroom #3 which were at least 6 feet apart. LPA observed a trash can without a tight-fitting lid near the kitchen door. Administrator told LPA he will purchase a new trash can with tight fitting lid.

Administrator provided training records on proper donning and doffing procedures of PPE. Administrator also showed vaccination records for 5 out of 5 residents and 4 out of 4 staff.

LPA observed adequate supplies of surgical masks, N95 masks, cleaning wipes, hand sanitizer, gowns, and face shields. PPE were stored in garage.

Administrator confirmed that visitation occurs in resident’s room or outside.

Administrator confirmed that all newly hired employees must provide proof of COVID-19 vaccination.

New residents need to quarantine for 14 days prior to staying at the facility.

Facility requires a negative COVID-19 test within 72 hours of new residents or employees entering facility.

At 11:49 AM, LPA and Administrator reviewed the facility’s mitigation plan (approved on 02/08//2021) to make sure administrator was following current infection control recommendations.

LPA Reed noted several discrepancies between the mitigation plan and the facility’s day-to-day procedures.

Administrator noted that the facility has not conducted COVID-19 testing in the past two months due to 100% vaccination status. LPA Reed reminded Administrator of the facility’s mitigation plan which outlines the requirement of testing 25% of staff each week. Since AAA Royal Senior Living Inc. currently employs four staff members, LPA recommended that one random staff tests for COVID-19 each week. LPA recommended Curative and Walgreens for staff testing. LPA will research pharmacies that come to smaller facilities and follow up with Administrator tomorrow, 10/15/2021.

Administrator stated that some nurses enter through the back door. LPA advised that all visitors and workers need to enter through the main entry point to screen for COVID-19 symptoms and check temperatures.

Administrator and staff check temperatures and symptoms on a daily basis, but do not maintain documentation. LPA required that staff and administrator must document temperatures and symptoms of residents and staff on a daily basis.

LPA conducted exit interview with Administrator.

LPA will email report

LPA also reminded Administrator of the annual licensing fee due on 11/08/2021.