Facility Evaluation Report

Licensing Program Analyst (LPA) K Walters arrived at this facility unannounced, to conduct an Annual Required 1 year inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Staff, Lexie Wilridge. The Administrator Dana Thomas arrived later. There are currently 4 clients residing in the facility and they receive services from North Bay Regional Center. The facility operates with 24 hour staffing.

LPA toured the facility with staff and made the following observations: LPA observed signs posted to promote droplet precaution at the entrance of the facility. There was also a sign-in sheet with a questionnaire for visitors and a thermometer to check visitors and client temperatures. There was at least a 30 day supply of Personal Protective Equipment and Incontinence Products.

Facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be charged and inspected 12/23/2022. The carbon monoxide and smoke detectors were tested. The smoke detectors were inoperable, however all of the carbon monoxide detectors were working. LPA observed that the toxins that were stored under the sink were not locked and were accessible to clients in care. In addition the medication cabinet was unlocked and accessible. The Administrator stated that they will replace the lock on the medication and toxins cabinet. LPA consulted with facility regarding the right yard gate that needs to be adjusted so it latches easily.