Facility Evaluation Report

Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced, to conduct an Annual Required inspection and met with Administrator Jethro Nicolas. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, staff checked LPAs temperatures. Facility has a binder for visitors to sign in. LPAs conducted a walk-through of the facility and observed Covid-19 posters including hand washing signs in the bathrooms. Per staff, clients are verbally reminded to wash and/or sanitize their hands. Hand sanitizer was observed throughout common areas of the facility and in client rooms. Facility is disinfected three times per day which includes disinfecting frequently touched surfaces. Clients are encouraged to wear masks when in the community. Staff were wearing masks during this inspection. Staff are screened for Covid at the beginning of their shift and Clients are screened during each shift.

LPAs and Administrator discussed client activities and visitation. Facility has a designated outside area for visitation. LPAs confirmed with Administrator that they are conducting vaccine verification for visitors per Provider Information Notice (PIN) 21-40-ASC. Staff have been trained on proper use of Personal Protective Equipment (PPE). LPAs discussed N95 fit testing options with Administrator. Facility has at least 30 days of PPE that is accessible to staff. Facility also has at least a 30 day supply of medication.

Facility has submitted their Mitigation Plan and it was reviewed by CCL. Administrator regularly reviews and follows the guidance outlined by the Provider Information Notices (PINs) sent by the department. Facility is complying with current vaccination guidelines.

Staff and LPAs discussed their Emergency Disaster Plan. Hard-wired combination smoke alarms and carbon monoxide detector were tested and operational. Fire extinguishers were last serviced December 2021.

No deficiencies cited during this inspection.