Facility Evaluation Report

At approximately 2:00 PM on 02/15/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection using the Infection Control Domain of the Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff and disclosed the reason for the visit.

Entry: At the main entrance, LPA observed emergency water supply and a sign on the front indicating the facility’s visitation policy. Once inside, LPA observed a confidential complaint posting and personal rights posting.

Screening: Upon entry, LPA was screened by staff. LPA recorded temperature, symptoms, and contact tracing information in a visitor log. LPA observed a screening station which contained a wall-mounted digital thermometer, a handheld digital thermometer, surgical masks, N95 masks, and sanitizer. LPA also observed a daily client temperature log.

At approximately 2:10 PM, LPA conducted a physical plant tour.

Safety: LPA observed Emergency Evacuation Plans with routes clearly labeled at the front entrance. Smoke detectors were functioning. Water temperature tested in Bathroom #1 was 118.2 degrees Fahrenheit and 115.5. degrees Fahrenheit in the kitchen. The emergency exits path was clear and unlocked with an inward latch.

Bedrooms: The facility had 4 private bedrooms. All bedrooms contained adequate storage space, clean linens, televisions, nightstands, and lights. In the event of a COVID positive client, the facility will designate Bedroom #4 as an isolation room.