Facility Evaluation Report

License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Required 1-year Infection Control Inspection of the facility. LPA was welcomed by Licensee/Administrator Janet Kirby for the visit. There is a total of 2 clients at the facility.

LPA initiated a tour of the facility at 2:05 PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation and adequate lighting. Water temperature at faucets accessible to clients measured within regulation of 105 degrees to 120 degrees F. Extra hygiene products are kept in the cabinet in the bathroom. Extra Linens are stored in the cabinet in the hall closet. Cabinet located under the kitchen sink containing cleaning supplies was locked. Facility has two days of perishable and one week of non-perishable foods for current census.

Fire extinguisher was fully charged. Smoke detectors located throughout the facility were tested and operational along with carbon monoxide detector was tested and operational as well. Disaster Drills are conducted 2 times a year with the last being November 17, 2021.

Facility has submitted a mitigation program plan that was approved, 3/24/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. The facility has a sufficient supply of personal protective equipment (PPE) stored in kitchen pantry. All staff have been fully vaccinated and received their COVID booster shots.