Facility Evaluation Report

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

Upon arrival, LPA observed posters outside notifying visitors that mask must be worn in the facility and the facility's visitation protocol. Once inside, LPA observed a screening station that included a thermometer and a log to track client and staff daily temperatures. Also observed were disinfecting wipes. Per conversation with staff and Administrator, the clients don't get a lot of visitors and those who do tend to visit outside. LPA confirmed with Administrator that if a visitor wanted to visit with a client indoors, that staff will screen them and conduct vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 9:10am 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 in common areas. Facility has bathrooms throughout with supplies for hand washing. Observed staff and many clients had masks on during this visit. Commonly touched surfaces are disinfected twice per day.

Facility has visiting areas outside. Staff have completed PPE training and facility has provided a round of N95 fit testing but will be conducting additional testing for new staff and those who may be coming up on their one year anniversary.