Facility Evaluation Report

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection with an emphasis on infection control. LPA identified herself to Administrator Kathy Goucher. Staff verified that the facility currently has no active and/or suspected COVID-19 cases.

During the inspection, LPA Bueno and Administrator Goucher toured the facility inside and out. LPA Bueno interviewed care staff regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA 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 continuously updates their COVID-19 mitigation plan.

LPA Bueno observed that the facility appeared to be meeting operational requirements. LPA observed that all utilities and appliances were functioning properly and all passageways clear of obstruction, including emergency exits. The facility was equipped with sufficient food supply and emergency supplies. All areas of the facility, including client bedrooms and restrooms, appeared clean and in good repair. Fire extinguishers were last checked in July 2022 and combination smoke detector and fire alarm were functioning.

LPA did not observe a visitor sign in sheet and a technical advisory is being issued. An exit interview was conducted where this report was discussed, and a copy of this report was provided to administrator at the conclusion of the inspection.