Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator Alyssa Joy Decano arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA was screened for Covid-19 by staff upon entry including having temperature checked and filling out a questionnaire with standard Covid-19 screening questions. LPA initiated a walk-through of the facility around 11:20am and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected three times per day. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) and have been N95 fit tested. Administrator and LPA discussed visitation and activities.

Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced November 2022. Facility has combination hardwired smoke and carbon monoxide detectors that are maintained and serviced by a vendor. The most recent service was conducted November 2022. Administrator provided proof of visit via an email with the vendor but tags have not been updated. LPA requested that Administrator reach out to the vendor to obtain updated tags for the fire extinguishers and the fire panel.