Facility Evaluation Report

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

LPA initiated an inspection of the facility around 12:35pm and observed the following: Covid-19 posters were posted throughout the facility including but not limited to hand washing and cough etiquette. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is available to clients in care. Per Licensee, they regularly discuss infection control with clients and staff. Clients are encouraged to wear masks when in the community and staff are required to wear them while in the facility. Observed staff had mask on during this visit.

LPA and Licensee discussed client activities and visitation. LPA also discussed facility vaccination percentage and their testing policy. Facility to review PIN 21-40-ASC regarding visitation, testing and vaccination verification guidance for visitors.

Caregivers have completed PPE training but has not been N-95 Fit tested. Commonly touched surfaces are disinfected twice per day.

Facility has submitted their Covid Mitigation Plan and it has been reviewed by CCL. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is located in an area that is accessible to staff who need it. Facility maintains a 30 day supply of medication.

Licensee and LPA discussed their Emergency Disaster Plan

No deficiencies cited during this inspection.