Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct a Post Licensing inspection

and met with Direct Support Staff, Nathaniel Neish. Administrator, Jenero Jefferson was unavailable during

inspection but was available by phone. The inspection is focused on the Infection Control procedures and

Upon arrival, LPA was asked to sign in and was screened for temperature. LPA conducted a walk-through of

the facility and observed Covid-19 posters throughout that included hand washing signs. Facility was a

comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout the

facility. Observed staff had N95 masks on during this visit. LPA informed staff that they may wear surgical

masks instead of N95 masks if there is no active Covid in the facility. Staff are screened before each shift for

Covid-19 symptoms and clients are screened twice per day. Temperatures are documented.

LPA and staff discussed client activities and visitation. Facility has a designated visitation area indoors and

outdoors. Facility does not have frequent visitors but does currently allow inside and outside visitation. LPA

instructed staff to review Provider Information Notice (PIN) 21-40-ASC regarding vaccination verification.

Commonly touched surfaces are disinfected twice per day, on the AM shift and the PM shift.. LPA has

requested Administrator to review all staff files to ensure that staff are adequately trained regarding infection

control and proper donning and doffing of PPE. Some staff have been N95 fit tested.