Facility Evaluation Report

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

Upon arrival, LPA observed Covid-19 posters on the front door instructing individuals to wear masks and to socially distance. Upon entry, LPA was screened by staff and results were documented. LPA confirmed with Administrator that facility is verifying vaccination for visitors per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility at around 11:45 am 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 throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected three times per day and after use. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in client rooms per CCL guidance. Staff continue to be trained regarding infection control and donning and doffing of PPE. Some staff have been N95 fit tested. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced August 2021. Facility has hardwired combination smoke and carbon monoxide detectors that were tested and operational during visit.