Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Direct Support Staff, Sandra Kruse. Administrator, Lindsey Gregori was unavailable. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by staff and results of LPA's temperature was documented. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout the inside of the facility and at the front door including but not limited to cough etiquette, hand washing, practicing social distancing, visitaiton policies and infection control . Per staff, clients are verbally reminded to wash and/or sanitize their hands frequently and receive physical assistance from staff, if needed. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility. Facility is disinfected at least twice per day which includes disinfecting frequently touched surfaces. Clients are encouraged to wear masks when in the community and when at day program. Staff wear masks while in the facility. Staff temperatures are checked when they come on shift and client temperatures are taken daily. Both are documented.

LPA and staff discussed client activities and visitation. Facility has a designated area for visitation. Per discussion with staff and review of records, N-95 Fit testing has been conducted and staff have been trained on Personal Protective Equipment (PPE). Facility has at least 30 days of PPE including gowns, surgical masks, N-95 masks, gloves, face shields and hand sanitizer that is stored in a central location and is accessible to staff. Facility also has at least a 30 day supply of medication.

100% of clients are vaccinated but staff was unsure what percentage of staff are vaccinated. Staff confirmed that unvaccinated staff are tested weekly per current CCL guidance.

Staff and LPA discussed their Emergency Disaster Plan. Facility had a fire inspection on August 24, 2021 which included testing smoke alarms. No issues were noted.

No deficiencies cited during this inspection.