Facility Evaluation Report

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

Upon arrival, Administrator showed LPA their visitor sign in book and confirmed that visitors are being screened. LPA initiated a walk-through of the facility around 11:20am 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 twice per day, per Administrator.

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). Staff have been N95 fit tested. Administrator and LPA discussed visitation and activities.

Facility has more than a 30 day supply of PPE including but not limited to masks, gloves, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced March 2022. Facility has a new fire system that was installed December 2022 and will be maintained by a vendor. Carbon monoxide detector was tested and operational.