Facility Evaluation Report

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 05/10/2022 at 1:30 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Staff Jennifer Culadilla and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. House Manager Ahmed Qasim was contacted and arrived at the facility during the visit. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with House Manager Ahmed Qasim. Per documents review, Mitigation Plan was submitted 02/12/2021.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility's client bedrooms and bathrooms and observed that both client bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE. LPA Brown went over the various recommended training for facility staff with House Manager Qasim in relation to COVID-19 and House Manager Qasim informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and House Manager Qasim informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results.