Facility Evaluation Report

On 12/27/21 at 3:10pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Plan of Correction (POC) inspection to ensure the facility is addressing and correcting deficiencies cited on 12/23/21 and to deliver 320 N95 masks to the facility.

LPA Gould arrived at the facility and was screened by front desk facility staff for COVID 19 and had temperature taken and recorded in the visitor log. LPA observed that other visitors were screened at the front desk and observed one visitor signing out of the log who was screen prior to entry. LPA attempted to meet with facility Administrator Carlie Beasley but were unable to meet as the Administrator was not at the facility at the time of inspection. LPA and Administrator met via facetime and together LPA and Administrator discussed corrections and steps the facility are taking to be in compliance with public health orders.

LPA and Administrator discussed the daily line list received on 12/27/21. LPA observed the line list is still incomplete and was missing COVID exemptions for unvaccinated staff. Administrator stated it would take approximately one week for the facility to have all exemptions received and on file for staff who remain unvaccinated. LPA inquired as to how the facility is notifying staff and asked the facility to accelerate their efforts to have all staff vaccinated or obtain an exemption. Administrator stated they are informing staff at the facility today and Administrator has informed department managers to notify the staff of the requirement. LPA again asked to accelerate the efforts and begin to reach out to staff at home or via email to inform them of the requirement. LPA Gould interviewed one staff member, S2 (see confidential names list, LIC 811 dated 12/27/21) who stated they were unaware of any changes or requirement to obtain an exemption if unvaccinated.

Report Continued on LIC 9099-C. Page 1 of 2.