Facility Evaluation Report

On 07/19/23 at 12:42 PM, 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 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, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer 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. Fire extinguisher was observed fully charged and last inspected 11/04/22, Comfortable temperature is maintained at 73 deg F. Hot water temperature was measured at 107 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. LPA reviewed 5 staff and 5 client files. LPA also conducted 2 staff and 2 client interviews during visit.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/20/23:

 LIC308- Designation of Facility Responsibility

 LIC610D- Emergency/Disaster Plan including infection control plans

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided .