Facility Evaluation Report

On 5/31/22 at 1:20 PM Licensing Program Analyst (LPA) Praveen Singh arrived unannounced to conduct an annual required inspection. 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. LPA contacted licensee and spoke with Michelle Wagner and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA met with Administrator Shoaaxum Johnson and discussed the purpose of visit. At approximately 2:00 p.m., Intake and Client Service Manager, Tanya Nalley, arrived to join the annual inspection visit. Facility has census of 3.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen & backyard.. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled at every 30 days. Facility has enough 2-day perishable food and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiency cited during the inspection. Exit interview conducted and copy of the report provided via email to Administrator.