Facility Evaluation Report

11/10/2022 Licensing Program Analyst (LPA) Shannon Diegoruelas, arrived at the facility

unannounced to conduct a Required-1 Year Inspection utilizing the infection control

domain. LPA met with Dominique Potter, Administrator and explained the purpose of the

visit. Prior to initiating the infection control annual inspection, LPA completed required

COVID-19 daily self-screening for symptoms of COVID-19 infection to affirm no

COVID-19 related symptoms. LPA contacted facility and completed a facility risk

assessment. LPA ensured they applied hand sanitizer before entering the facility and the

following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally,

LPA and the administrator toured facility to ensure health and safety of residents in care.

Areas toured include but are not limited to: common areas, out door area, three (3)

bathrooms, four (4) resident rooms, kitchen, and storage areas. In the areas toured no

immediate health, safety, or personal rights violations were observed. LPA and the

administrator completed the infection control domain and facility was found to be in

No deficiencies are being cited because of today’s inspection.

Exit interview conducted and copy of report was provided to the Licensee.