Facility Evaluation Report

Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer met with administrator Adlean Fisher-Ashley and discussed the purpose of today's visit. This single-story home contains two (2) client bedrooms, an office, two (2) bathrooms, a living room, kitchen, dining area, attached garage, and backyard.

The facility had a universal entrance screening area including a thermometer, sign-in log, and PPE.

COVID-19 signage was placed in several areas and temperature logs were maintained.

Facility maintained a 30-day supply of PPE.

There was a sufficient supply of 7-day supply of non-perishable foods, but insufficient supply of non-perishable foods due to no fresh fruits. The staff picked up more food items prior to the end of visit.

Sharps and cleaning solutions were locked and inaccessible.

Each room contained required furniture: bed, dresser, night stand, lamp/light and chair.

All beds contained the required linen: mattress cover, fitted sheet, flat sheet, blanket, and comforter.

Bathrooms contained supplies including liquid soap, toilet paper, and paper towels.

Medications were locked and centrally stored. There was missing medication for one (1) resident: empty container of Lactulose 10g/15 mL was observed. The administrator ordered and had medication delivered prior to the end of the visit.

Smoke detectors/carbon monoxide detectors were present and operable.

A fire extinguisher was observed to be fully charged and last serviced February 2021.

All client files were inspected: emergency contact information and physician's reports were up-to-date.

All staff files were inspected and contained required health screenings, criminal record clearances, first aid/CPR certificate, and training certificates. An updated administrator certificate was observed and expires on 5/23/2023.

Pursuant to Title 22, a deficiency was cited on attached 809D. An exit interview was conducted and a copy of this report and Appeal Rights were provided to the licensee.