Facility Evaluation Report

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

Upon arrival, LPA was screened by staff including having temperature checked. Per Administrator, clients don't really get visitors that visit inside the facility but they screen visitors. LPA discussed conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC with Administrator. LPA initiated a walk-through of the facility around 8:45 am and observed the following: Facility was a comfortable temperature and exits were free from obstructions. There is notification on the front door notifying visitors that they will be screened upon entry. LPA discussed the lack of posters in the facility with the Administrator who explained that staff must verbally remind clients to wash their hands and socially distance. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected daily. LPA reminded Administrator to document daily screening for staff and clients and for when visitors come to the facility.

Facility has a designated visitation area outside and is allowing for visitation inside facility per CCL guidance. LPA discussed ensuring that training for infection control and proper donning and doffing of PPE is incorporated into their annual training. Per Licensee, they frequently go over donning and doffing of PPE with staff. LPA and Licensee discussed visitation and activities.

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 gloves, masks and hand sanitizer. LPA suggested getting gowns in case a client becomes positive. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced July 2021. Smoke and carbon monoxide detectors throughout facility were tested and operational.