Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee, Rita Larson. LPA conducted a Risk Assessment call with Administrator prior to the visit.

Upon arrival, LPA observed posters on the front door pertaining to Covid-19, LPA had their temperature checked, was screened at the entrance and staff documented readings. The facility does document symptoms or temperatures of staff prior to start their work shift and client's at bedtime. LPA conducted a walk-through of the facility with the staff and observed Covid-19 posters throughout the facility including hand washing posters in bathrooms. Hand sanitizer is kept in the common area of the facility but not throughout due to safety concerns. Facility has multiple bathrooms that are kept stocked with hand hygiene products. Clients were observed wearing masks and they are required to wear a mask when they are in common areas or outside of the facility due to facility has one client and one staff that are not vaccinated. Staff are required to wear masks while in the facility and were observed wearing masks during this visit. Facility has a contract with alternative care center is able to provide isolation rooms for clients, this center includes medical staff, meals and vitals checks if needed. Facility has submitted a mitigation program plan and was approved on 6/10/21. Facility has a 30-day supply of medication for clients. Facility has a designated outdoor visitation area. Facility has conducted staff training on infection control and have been N95 fit tested. Commonly touched surfaces are disinfected at least twice a day by staff. Facility has 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer and it is located at a place that it is accessible to staff.

Licensee agreed to submit updates of the following documents by 9/24/21: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Affidavit regarding client (LIC400), Surety Bond (LIC402) .

- No deficiencies cited during this inspection.