Facility Evaluation Report

On today's date around 11:45am 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 Beverlee Milam, 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. In addition, Staff screened LPA prior to entering the facility.

LPA toured facility with Administrator to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, bathroom, office, isolation room, kitchen, 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.

During the inspection, LPA requested for a copy of LIC 500. A copy of the facility's updated emergency disaster plan was submitted to Licensing on 1/31/2022.

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.