Facility Evaluation Report

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/12/22 to conduct a Annual Inspection utilizing the infection control domain guidance. LPA met with the Director and explained the purpose of the visit. Prior to initiating the 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 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 caregiver upon entering the facility.

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

LPA advised: maintaining visible hand washing signs at all hand washing sinks, maintain record of staff not fully vaxed who require weekly testing, maintain thorough screening of all visitors and staff, purchase trash cans with no touch lids for PPE disposal, routinely review mitigation plan to ensure accuracy/ update as needed.

LPA requested Administrator submit: client roster and staff roster to CCL by 4/19/22.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report