Facility Evaluation Report

Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer was greeted by administrator Otis Lee Bennett and discussed the purpose of today's visit. This single-story home contains two (2) client bedrooms, one (1) client bathroom, three (3) family bedrooms, (1.5) family bathrooms, a living room, den, kitchen, laundry room, 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 of the facility and client temperature logs were maintained, however, staff temperature logs were not maintained.

Facility maintained a 30-day supply of PPE.

There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods.

Cleaning solutions including bleach, laundry detergent, and Microban 24 were not locked and inaccessible. The administrator immediately made them inaccessible.

Each room contained required furniture including bed, dresser, night stand, lamp and chair.

All client beds had 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. However, two (2) over-the-counter medications, Aspirin 81 mg and Vitamin B12, were observed and did not contain physician's orders and labels.

Staff wore face masks consistently throughout the shift and group activities were spaced to encourage physical distancing.

Smoke detectors/carbon monoxide detectors were present and operable.

A fire extinguisher was observed to be fully charged and last serviced December 2020.

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

All staff files were inspected and contained required health screenings, criminal record clearances, and training certificates. Administrator certificate was up-to-date expires March 2023.

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