Facility Evaluation Report

Licensing Program Analyst (LPA) Willis arrived unannounced to conduct an Annual inspection visit and met with Program Manager, Briana Terrell-Bachelor. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPA was asked to sign in and fill out a questionnaire with standard Covid-19 screening questions. Temperature was checked and documented. 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 including hand-washing signs in the bathrooms. LPA observed staff were wearing masks. Participants also wear masks while in the facility. During inspection, participants were eating lunch. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Bathrooms had hand washing supplies and hand sanitizing dispensers were observed throughout the facility.

Staff receive training on infection control and proper donning and doffing of Personal Protective Equipment (PPE). Facility has a janitorial company that cleans and disinfects the facility at least twice per day which includes bathrooms and frequently touched surfaces. Staff clean and disinfect areas after use. Facility has at least a 30-day supply of PPE. Staff and participants are screened daily for COVID-19 symptoms and it is logged. Facility is following vaccination the guidance per PIN 22-05.1-ASC.

Fire Extinguishers were last serviced January 2022. Facility is located in a building that has a management company who is responsible for maintenance of the fire system.

No deficiencies cited during this inspection.