Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with House Manager Jhanell Edmalin. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA/House Manager initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include 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. Commonly touched surfaces are disinfected at least twice per day. Facility does perform daily screening of staff and residents and documents it. Facility is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control, donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguisher was last serviced June 2022. Smoke Detectors and Carbon Monoxide detector were tested and found operational. All clients do attend to day program and facility provides activities for clients as well.

Facility will provide copies of the following documents by 2/23/23: Designation of Responsibility (LIC308), Administrative Organization (LIC309), Affidavit Regarding Client Cash Resources (LIC400), Surety Bond, Control of Property (Deed, property tax, etc), Personnel Report (LIC500) and LIC 610 Emergency Disaster Plan. Exit interview conducted with House Manager and a copy of this report was given.

No deficiencies cited during today's inspection.