Facility Evaluation Report

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual inspection on October 29, 2021. LPA met Administrator Eldridge, identified herself and explained the purpose of the visit.

LPA, accompanied by Administrator Eldridge conducted an overall tour of the facility, and observed and spoke with clients in care. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements that are most relevant to protecting the health of clients in care and staff, including in the area of infection control practices.

LPA reviewed current Community Care Licensing (CCL) guidance to incorporate in the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Administrator Eldridge including but not limited to the following sections: staff vaccination requirements and staff and consumer vaccination tracking, and visitation guidelines. LPA reviewed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, ability to quarantine or isolate if necessary and essential health and safety.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, clients and visitors; a sign-in policy; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and as much as possible, residents; hand sanitizer/hand washing stations readily available; a designated visitation area if necessary; emergency agencies’ contact information posted in a location visible to staff and clients; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.