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. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors that mask must be worn in the facility. Once inside, LPA observed a screening station near the entrance along with a visitor sign in. LPA confirmed with Direct Support Staff that facility is conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that included 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. Observed staff had masks on during this visit. LPA discussed disinfecting commonly touched services more frequently, at least once per day. Facility maintains documentation of staff and client daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Facility continues to train staff on PPE and infection control. LPA and Direct Support Staff discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced November 2021. Smoke and carbon monoxide detectors throughout facility were tested and operational.