Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Paula Finley (Chief of Services). This inspection is based on infection control practices at this facility. Currently the facility is operating with 68 participants on-site Monday-Friday between 8:00am to 4:00pm.

The building is housing some administration offices, changing rooms, lunchroom, multiple areas used for activities and staging areas for participants who go out into the community. Facility was a comfortable temperature and passageways were free from obstructions. Facility has two centralized sign-in system located at loading area and facility entrance where facility documents staff, visitors and participants. Facility provides transportation services by R&D for some participants that ensures to follow current guidelines. Participants bring their own snacks and lunches. Staff was observed wearing a mask while in the facility. Participants wear face coverings as tolerated. All staff continues receiving required training on infection control, but they have not been N95 fit tested. Regular maintenance plan includes sanitizing and cleaning after conclusion of each activity. Facility has automated dispensers to dispense hand sanitizer. Facility has submitted their Mitigation Plan and Infection Control Plan for CCL's review. Facility has posters that are posted through the facility encouraging participants to wear a mask, wash their hands, cough etiquette and maintain social distancing. Facility has sufficient personal protective equipment for staff and participants including gloves, hand sanitizer and masks. Last disaster drill was conducted on February 8, 2023, Fire extinguisher was last inspected April 2022. Facility smoke alarms and carbon monoxide detectors are hard wired and inspected and maintained by a vendor. Most recent inspection from the local fire department was conducted 11/21/2022. Medication is centrally stored and locked in the support team office.

Facility will provide updated copies of the following documents by 3/6/23: Designation of Responsibility (LIC308) and Personnel Report (LIC500). Exit interview was conducted with Chief of Services and a copy of this report was given. No deficiencies were cited during today's inspection.