Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Shelly Pefley and Program Manager Sara Heringer. 7 Clients were present at the facility. Due to COVID-19 protocols, the facility has 2 cohorts: one meeting Monday, Wednesday and Friday (averaging 9 clients), and the second cohort meets Tuesday and Thursday (with approximately 9 clients). There are an additional 18 clients, that receive remote/drop-off/Zoom services. The facility operates from 9 AM to 12 PM.

LPA arrived at the facility and had temperature checked, screening questions asked and logged into visitor’s binder located at the entrance to the facility. Staff and clients are also screened and information logged prior to entry. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The common areas, kitchen, laundry, isolation room, 4 bathrooms and art room were inspected. 2 fire extinguishers were found to be last charged and inspected on 01/21/22 and the fire detection/sprinkler system was inspected on 05/22/22. Toxins are stored in a locked cabinet inside the laundry room. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients.

Facility submitted a mitigation program plan on 06/02/21. Posters have been placed at entrance and by sinks as well as other areas of the facility reminding staff and clients of good hygiene practice. A table with hand sanitizer and other items designated for visitors are placed at entrance.

Administrator is currently working on the new Infection Control Plan.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.

No deficiencies cited during this inspection.