Facility Evaluation Report

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

LPA observed a screening station upon arrival which included a temperature check and a request for visitors to complete a questionnaire with standard Covid-19 questions. Participants and staff are also screened in this area and documentation is maintained. LPA initiated a walk-through of the facility around 12:40 pm and observed the following: Facility has COVID-19 posters throughout each suite that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Facility continues to maintain an isolation room. Facility has some participants who are not yet attending program in person and they provide remote services to them. Observed staff had a masks on during this visit.

Staff have incorporated training on infection control and donning and doffing of Personal Protective Equipment (PPE) into their regular training schedule. Facility has staff N95 fit tested. Commonly touched surfaces are disinfected three times per day; once in the morning, after lunch and then after all participants have left for the day. Bathrooms are disinfected after use.

Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, gloves and hand sanitizer. Fire extinguishers were last serviced August 2022. Facility is located in a commercial building and the fire system is monitored and maintained by the landlord.

Administrator and LPA discussed their Emergency Disaster Plan, Mitigation Plan and Infection Control Plan.

No deficiencies cited during this inspection.