Facility Evaluation Report

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

Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and answering standard Covid-19 screening questions. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility around 2:40pm 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. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility continues to screen staff and clients and maintains documentation.

Facility has a designated visitation area outside and is allowing for visitation in client rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) and have been N95 fit tested. LPA and Administrator discussed visitation and activities.

Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, gloves and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced June 2022. Facility has a fire system (which includes Carbon Monoxide detectors) that is maintained and monitored by a vendor. The most recent service was conducted January 2022.