Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a required 1- Year infection control visit, and was greeted by staff. The Administrator was contacted via phone. This visit will focus on the infection control of this facility. The facility submitted a mitigation plan which was approved by Community Care Licensing on 06/03/2021 and an Infection Control Plan on 08/08/2022.

When LPA arrived at the facility, staff checked LPA's temperature and signed LPA in using a sign in sheet. It was observed that the two (2) staff members present were wearing masks. Five (5) clients were on site at the time. Signs were posted at the entrance to inform visitors that a mask must be worn while inside the facility. Bathrooms were supplied with hand washing supplies and paper products. Facility has a limited amount of Personal Protective Equipment. There were two main activity rooms and an independent working area and staff office. LPA arrived at the end of the daily session; residents were prepared for transportation to take them home. Toxins were kept inaccessible to clients in care in a storage closet in one of the bathrooms. The fire extinguishers were last serviced on 10/17/22, and all three (3) were fully charged. LPA observed one (1) carbon monoxide detector in the facility, which was operational. Facility has hardwired alarms which are tested yearly. The facility was a comfortable temperature of 71 F. Clients provide their own lunches daily; staff help them in heating anything up with an available stove or microwave. Clients' medications are kept on site in a locked cabinet and dispersed as required via doctor's orders.

The facility was decorated for the Valentine's Holiday with a variety of heart projects made by the clients.

There were no deficiencies found at the time of inspection. No citations issued.