Facility Evaluation Report

Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain on today's date and met with Rhea Dodd, Administrator. LPA explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. In addition, Administrator screened LPA prior to entering the facility.

During the inspection, all 4 clients and 2 staff were present at the facility. LPA toured facility inside and out with Administrator to ensure health and safety of clients in care. Areas toured include but are not limited to: common area, office area, 4 client bedroom, 1 shared bathroom, laundry room, kitchen, dining area, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

Facility has 30 days supplies of PPE available at the facility. LPA reviewed 2 of 2 clients Centrally Stored Medications. All medications had a physician's order on file and were all logged on Centrally Stored Medication Logs. LPA reviewed 4 of 4 clients P&I Money. P&I were locked and not kept with facility money. Facility has 7 days of non-perishable and 2 days of perishable food supply on today's date to meet the dietary needs of 4 clients in care.

During the inspection, LPA and Administrator discussed the facility's infection control and mitigation plan.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of this report was left at the facility.