Routine inspection·September 22, 2021

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced annual required licensing inspection. LPA was granted entry by Co-Administrator Celia Luke. LPA was granted entry after identifying themselves and disclosing the purpose of their visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Administrators Celia and Kevin Luke, including the following sections: Person in Care, Staff, Visitors, Facilities without COVID-19, Residents, Plans for Infection Control and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and face coverings recommended to residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit. An exit interview was conducted with Administrator Kevin Luke and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) was provided to them via email; an email read receipt confirms receipt of this report and these rights