Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Victor Dada. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA rang the doorbell at the gate multiple times and called the Licensee. LPA waited for approximately thirty minutes until Licensee answered the phone. LPA discussed concerns with Licensee regarding wait times, specifically if residents were able to alert staff if they needed assistance during the night. LPA confirmed that the doorbell on the gate does work and the alert goes to the Licensee's phone. LPA suggested turning up the phone or using a different device. Caregiver showed LPA the motion detector that is used in the resident's room in case they get up in the night and is loud enough to alert staff.

LPA observed Covid posters on the front door. Once inside, LPA observed a screening station near the entrance along with a visitor sign in. LPA confirmed with caregiver that they are screening all visitors. Facility is not currently conducting vaccine verification noting that there is only one person who visits. LPA directed caregiver to verify vaccination status of all visitors per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility at around 8:55 am and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected once per day.