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25 | On 04/09/24 at 2:14PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA observed current administrator certificate # 6035565740 which expires 06/02/2025.
At 2:30PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers 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 cabinets. Comfortable temperature is maintained at 74 deg F. Hot water temperature was measured at 115 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 08/11/23. LPA reviewed 5 staff and 5 resident files. LPA also conducted 2 staff and 2 resident interviews during visit.
No deficiencies observed during visit.
Updated copies of the following documents were collected for facility file:
LIC500- Personnel Report
Residents Roster
LIC308- Designation of Facility Responsibility
LIC610E- Emergency/Disaster Plan including infection control plans
Evidence of Liability Insurance
Exit interview conducted and a copy of this report provided. |