Routine inspection·November 2, 2021

Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA Brown was greeted and granted entrance by Administrator Kelly Evans and LPA Brown explained the purpose of today's visit. Administrator Evans accompanied LPA Brown on a tour of the inside and outside of the facility. During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. During the outside tour of the facility, LPA Brown observed locked perimeter fence gate, which Administrator Evans stated that she had to locked it to prevent resident from wandering. Administrator also reported that 1 of 2 of their residents has mild dementia. The facility does not have approval for any form of locked perimeter, and this style of locking is not permitted, as residents might not be able to exit in an emergency. LPA Brown informed Administrator that it needs to be removed immediately. An exit interview was conducted with Licensee/Administrator Kelly Evans and a copy of this report (LIC 809) and LIC809D, appeal rights were provided.