Facility Evaluation Report

Licensing Program Analyst (LPA) Rohit Lama made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA identified himself to Staff #1 (S1) and discussed the purpose of the visit. Prior to entry, facility S1 ensured that LPA was masked. The Program Director stated that all staff are tested and that there are not any individuals currently with COVID symptoms.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.

During the inspection, LPA Lama interviewed the Program Director pertaining to the facility's infection control measures and other health and safety concerns. LPA Lama observed necessary signs posted in the facility, including signs related to COVID-19, which were in accordance with the Department's guidelines. The Program Director stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. LPA observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, 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 of clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the client presents any COVID-19 symptoms.