Facility Evaluation Report

Licensing Program Analysts (LPA) Victoria Willis and Caitlynn Felias arrived unannounced, to conduct an Annual Required inspection and met with House-Manager, Mary Foster-Brown. Licensee, Zina Lee was available by phone. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, staff checked LPA's 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 was a comfortable temperature and exits were free from obstructions. Facility is disinfected one to two 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.

LPAs and House Manager discussed client activities and visitation. Facility has a designated outside area for visitation. LPAs confirmed with House Manager 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). Per conversation with Licensee, will receive additional training for Covid-19 and will be fit tested in January 2022 by the local Department of Public Health. 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. Licensee 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. Two smoke alarms, one upstairs and one downstairs, and carbon monoxide detector were tested and operational.

No deficiencies cited during this inspection.