Facility Evaluation Report

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

Upon arrival, LPA was greeted by Licensee. LPA discussed facility screening policy with Licensee who stated that facility does not really get visitors but staff do screen visitors when they come and are conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 11:45am 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 three times per day. Facility continues to screen staff and clients and maintains documentation

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). LPA and Licensee 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 April 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational. Licensee and LPA discussed their Emergency Disaster Plan and Infection Control.

Licensee/Administrator to submit updates of the following documents by 10/23/2022:

No deficiencies cited during this inspection.