Facility Evaluation Report

Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of conducting a Required 1 Year annual inspection. LPA met with Jacqueline Hicks, Administrator. This visit will focus on the infection control of this facility. The facility submitted an infection control mitigation plan on 01/06/2022 which was approved by Community Care Licensing. The facility currently has 2 clients in care.

LPA toured the facility and grounds with Administrator and made the following observations: COVID-19 precaution signs posted in common areas to promote social distancing. The facility has designated the garage as the visitor check-in area. There, LPA was screened for COVID-19 symptoms and had temperature checked. LPA also observed at least a 30 day supply of Personal Protective Equipment (PPE), incontinence products and cleaning products. Upon entrance to the facility, the Administrator has posted COVID-19 reference sheets for staff. Other Infection control practices that are present are: creating designated visiting areas, face coverings and sick leave policy. Per Administrator, Staff disinfectant daily and after usage.

LPA reviewed staff and client records which indicate that staff and clients have received their vaccines. Vaccine records are stored in client and staff files. LPA and Administrator discussed documenting staff infection control training's, including the duration and topic, and having training's signed by staff. Client's are screened daily on Medication administration records (MAR). Clients and staff who are not vaccinated are tested twice weekly. Internal and External group activities are developed weekly, that foster physical distancing. Facility has an activity board which includes museum outings, parks and trips to farmers market.

During visit LPA learned of an incident occurring earlier in the day on 4/12/22. LPA gathered additional information regarding the incident. This incident will require further follow up. Administrator was unable to complete visit with LPA. LPA conducted exit interview with Adlaine Alfonso, back-up Administrator. No deficiencies cited during today's visit. Nothing further. This is an amended report.