Facility Evaluation Report

At approximately 2:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-year required Annual Visit and met with Direct Support (DSP), Lushell Frazier. Administrator, Shaquila Smith, was available by telephone, and gave permission for DSP to sign report. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. Hand Sanitizer was readily available for use throughout the facility. Toxins and detergents were secured and inaccessible to residents. Medications were located in the medication cabinet that was locked and inaccessible to residents. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

LPA and Administrator discussed facility's plan for staffing if a shortage occurred.

Facility has a cleaning and disinfecting schedule that occurs two to three times per shift. Facility has at least a 30-day supply of PPE and medication for clients. Staff and clients are screened daily for COVID-19 symptoms and it is logged into facility binders.

Fire Extinguishers were last serviced July 2022. Carbon Monoxide detector were tested and operational. LPA observed that 2 of 4 Smoke Detectors were out of operation due to the batteries being taken out and not being replaced. Per conversation with DSP, one of the clients took the batteries out and they were not put back in. LPA and Administrator discussed the importance of ensuring batteries are placed back into the detectors.