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25 | On 12/20/21 at 10:00 AM, Licensing Program Analyst (LPA) Toan Luong conducted a facility risk assessment with Administrator Natasha Gill. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Staff Ana Lainez and Staff Nathaly Chavez and explained the purpose of the visit.
Staff took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.
The facility is an Adult Residential Facility. During the facility tour LPA advised posting of signs encouraging social distancing, hand washing, and cough etiquette. LPA advise having CDSS PINs readily accessible to residents, visitors, and staff. LPA advised facility to fit-test staff. Facility did not have a 30-day supply of PPE. LPA observed 5 boxes of 20 count N95 masks, three boxes medium size gloves. Facility had an adequate supply of other PPE. LPA inquired if licensee has an additional facility in which supplies may be obtained from without affecting 30-day supply or to request additional supplies from TCRC or CCLD. Facility has one bedroom with beds not 6 feet apart, but additional bed is unused. LPA observed thermostat having low battery and recommended replacement to maintain temperature within regulation.
LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Staff Nathaly to satisfaction.
Exit interview was conducted. No deficiencies cited and report emailed to administrator. |