Facility Evaluation Report

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

Upon arrival, LPA was screened by the Administrator for Covid-19 symptoms and temperature was taken. Facility has Covid-19 posters at the front door and a hand washing sign in the kitchen near the sink. LPA confirmed that staff are conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASCs. Facility is unable to keep posters in restrooms and in other parts of the facility as they get removed by clients. Facility is unable to store hand sanitizer in client rooms per safety precautions but clients and staff are encouraged to wash their hands frequently and hand sanitizer is centrally located. Per staff, infection control is regularly discussed with clients and staff. Facility was a comfortable temperature and exits were free from obstructions. Staff and clients are screened for Covid-19 symptoms once per day and results are documented. Commonly touched surfaces are disinfected at least once per shift and as needed.

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, face shields, gowns and hand sanitizer. PPE is located in the living room and is accessible to staff who need it. Staff continue to wear masks while in the facility, per CCL guidance.