Facility Evaluation Report

On today's date around 10:15am, Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Donna Mallet, staff. 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. In addition, Staff screened LPA prior to entering the facility.

LPA toured facility with staff to ensure health and safety of clients in care. Areas toured include but are not limited to: 2 activity rooms, staff office, kitchen, storage cabinets, and isolation room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Staff completed the infection control domain and facility was found to be in substantial compliance at this time.

During the inspection, LPA and staff discussed the facility's screening process, posting of posters, isolation room set-up, N95 Fit Testing, social distancing in the facility, and vaccination/boosters requirements for staff.

LPA advised staff to review Mitigation Plan and keep an updated one readily available at the facility.

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.