Facility Evaluation Report

Licensing Program Analyst (LPA) T. White arrived unannounced on this day for the purpose of conducting a required 1-year annual inspection. LPA arrived at 1:20 PM and met with Executive Director (ED), Karyn Gregorius. Present at the facility on this day was 16 clients and 10 staff.

At 1:35 PM, LPA toured the facility with ED Gregorius and inspected food services. Clients provide their own lunches but facility does have a plan in place for meals if needed. LPA observed facility does not manage medications. LPA inspected isolation room, which was clean and odor free. Bathroom was inspected and hand washing areas were clean. Hot water was measured in clients shared bathrooms at 119.3 and 118.4 degrees F. Temperature measured at 72 degrees Fahrenheit. ED stated facility reopened 09/13/2021. Fire extinguisher was last inspected on 09/28/2021. LPA observed mitigation plan completed. Facility has a 30 day supply of Person Protective Equipment (PPE) available. LPA observed smoke detector and carbon monoxide in operating condition during inspection. Fire drill was last conducted on 09/28/2021. Emergency Disaster plan updated on 10/01/2021. LPA reviewed 2 clients and 2 staff members files.

During inspection, LPA observed clients practicing social distancing.

LIC 308 - Designation of Facility Responsibility

No deficiencies cited during inspection. Exit interview conducted with ED and a copy of report given.