Facility Evaluation Report

11/30/2022 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 Tavarius Simmons, Direct Care Staff 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 direct care staff toured facility to ensure health and safety of residents in

care. Areas toured include but are not limited to: outdoor area, common areas, 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 direct

care staff 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 Administrator