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25 | Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Administrator, Joana Dimaculangan. The inspection is focused on the Infection Control procedures and practices of this facility.
Upon arrival, LPA observed that the facility has Covid related posters on the exterior door and a screening station at the entryway. LPAs temperature was checked upon entry to the facility and Administrator requested that LPA sign in and answer standard Covid-19 screening questions. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout that included hand washing signs in bathrooms and PPE donning and doffing instructions on client bedrooms doors. Facility has individual PPE carts in front of each bedroom at all times. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizers mounted to the wall were observed throughout the facility including at the entrance to client rooms. Staff are required to wear masks while in the facility and LPA observed staff had masks on during this visit. Clients are screened twice per day and staff are screened when coming on shift. Documentation is maintained.
LPA and Administrator discussed client activities and visitation. Facility has a designated visitation area outside and allows for inside visitation per CCL guidance. Administrator confirmed that they are conducting vaccine verification for visitors per CCL guidance.
Caregivers have completed recent Personal Protective Equipment (PPE) training and have been N-95 Fit tested. Commonly touched surfaces are disinfected on each shift and documentation is maintained.
Facility has submitted their Covid Mitigation Plan and it has been reviewed by CCL. Facility has more than a 30 day supply of PPE including but not limited to surgical masks, N95 masks, face shields, gowns and hand sanitizer. PPE is accessible to staff who need it. Facility maintains a 30 day supply of medication.
Administrators and LPA discussed their Emergency Disaster Plan
No deficiencies cited during this inspection. |