Facility Evaluation Report

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

Upon arrival, LPA was screened by the administrator which included checking temperature and signing in. LPA confirmed that visitors are screened and vaccination verification is being conducted per Provider Information Notice (PIN) 22-07-ASC. LPA conducted 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. Commonly touched surfaces are disinfected four times per day. Facility maintains documentation of staff and client daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation indoors per CCL guidance. Staff have completed PPE training but have not yet been N95 fit tested. Per Administrator they frequently go over donning and doffing of PPE with staff and provided LPA with some training logs. LPA and Administrator 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 are not yet due for servicing. Hardwired smoke and carbon monoxide detectors were tested and operational.