Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator, Jennica Narciso arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by staff and asked to sign in and complete a questionnaire with standard Covid-19 screening questions. LPA confirmed with Administrator that facility was conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 1:15pm 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. Commonly touched surfaces are disinfected once per shift. Facility continues to screen clients for Covid-19 daily and maintain documentation.

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Staff continue to receive training on infection control and Personal Protective Equipment (PPE). LPA and Administrator discussed visitation and activities.