Facility Evaluation Report

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

Upon arrival, LPA completed a signed-in sheet and answered standard Covid-19 screening questions. Staff checked LPA temperature. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout that included hand washing signs in the restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is centrally located to ensure client safety. Facility has hand washing supplies in bathrooms and kitchen. Per Administrator, they regularly discuss infection control with clients and staff. Clients are encouraged to wear masks when in the community and staff are required to wear them while in the facility. Observed staff had masks on during this visit.

Commonly touched surfaces are disinfected on each shift. Staff have received training on proper use of PPE and receive ongoing guidance regarding Covid-19 protocols. LPA and Administrator discussed client activities and visitation. Fire extinguishers were last serviced December 2021. Hardwired smoke alarms were tested and operational during inspection.

Facility has submitted and received their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is located where it is accessible to staff who need it. Facility maintains a 30 day supply of medication.

LPA confirmed that facility is signed up to receive Provider Information Notices and is aware of the most recent Covid-19 guidance from CCL.

Backup Administrator and LPA discussed their Emergency Disaster Plan.

No deficiencies cited during this inspection.