Facility Evaluation Report

Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to conduct a required annual inspection, with an emphasis on infection control, due to the COVID-19 pandemic. LPA Williams identified herself to Case Manager, Tammy Higgins, who was also informed of the purpose of the visit. LPA Williams was screened for COVID-19 symptoms upon arrival. Higgins stated that at this time, the facility is not conducting in-person program; however, they are conducting program virtually.

During the inspection, LPA Williams interviewed Higgins regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA Williams observed appropriate postings in the facility, including COVID-19 symptoms postings and Personal Rights postings, which were in accordance with the Department's guidelines. LPA Williams observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

Furthermore, LPA Williams observed that the facility appeared to be meeting operational requirements. LPA Williams observed that all utilities and appliances were functioning properly and all passageways clear of obstruction, including emergency exits. The facility was equipped with several first aid kits and emergency supplies. All areas of the facility, including common activity rooms and restrooms, appeared clean and in good repair. LPA Williams observed that there was a designated area for locked medications and dangerous objects. LPA Williams observed no apparent health and safety risks at the time of visit.