Facility Evaluation Report

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/24/21 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Program Director and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and upon arrival completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior 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, bathroom, kitchen.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Program Director completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA advised facility keep hand sanitizing supplies at the client/guest entry,extend the client/guest screen to include all covid symptoms, create quality assurance that twice daily sanitizing is completed/ documented and that N-95 respirators are Fit tested for all staff.

LPA requested for documents such as, resident roster, LIC 500, the last signature page of the LIC 610E be submitted to LPA via email by due date on, 8/30/21.

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

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