Routine inspection·December 10, 2021

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced annual required licensing inspection. LPA met with Executive Director, Meegan Kline. LPA stated purpose of today’s visit, to verify 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. During today’s visit, LPA toured the facility and reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Executive Director including the following sections: Person in Care; Staff; Visitors; Residents; Facilities without COVID-19; and Facility has 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. Facility as a gated safety security kiosk, the safety officers conduct screening on all individuals entering the community. 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; hand sanitizer/hand washing stations readily available; 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, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Executive Director via electronic mail. An electronic mail read receipt was requested to be provided upon receipt of the documents.