Facility Evaluation Report

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/2/22 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with associate director and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and self assessment. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Administrator was unavailable for the inspection.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and associate director completed the infection control domain and facility was found to be in basic compliance at this time.

LPA advised: More robust screening of visitors, staff and clients for known symptoms and consistent documentation; increased signage and PIN information be available to clients and staff; Human Resources submit proof of weekly testing for staff who require it; HR review the Guardian staff roster to ensure all staff are associated; Increase encouragement and education of client to use mask and maintain physical distance in common areas; and provide Fit Testing to staff for N-95 use.

LPA will email additional resources and information.

LPA requested for documents such as LIC 500, Administrator's Certificate and last page of LIC 610E Documents to be submitted to LPA via email by due date 8/12/22.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.