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25 | Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff, Talise Jovel and Gianna Louis. Licensee was not able to come to the facility but gave authorization for staff to sign the report. LPA conducted a Risk Assessment call with staff. LPA/staff reviewed PIN 22-05, PIN 22-06, PIN 22-07 and PIN 22-09.
LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least three times a day. Facility has antigen tests in stock to use for visitors. Facility is able to accommodate a single room for each client that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols, but has not been N-95 fit tested. Staff and residents are being monitored daily. However, screening results are not documented. Facility maintains a 30 day supply of medication. Facility has one out of five staff vaccinated, but not boosted yet. There are four exemptions on file for 4 out of 5 staff. One out of two clients is not vaccinated, the facility doesn't have an exemption on file for this client and doesn't attend to day program, but they do attend to church zoom classes in average of twice a week. will submit an exemption for client (C1) to CCL for review. Other client attends to day program in an average of twice per week. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has submitted their Covid Mitigation Plan and approved on 3/12/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff. Licensee will provide updates of the following by 3/24/22: affidavit regarding client/resident cash resources (LIC400) and surety bond. No deficiencies cited during this inspection. |