Routine inspection·January 20, 2023

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Executive Director Morgan Holien and Health Services Director Jody Livingston. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and signing in. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least twice per day. Facility continues to screen staff and residents and maintains documentation. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE but have not been N95 fit tested. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Facility has submitted their Emergency Disaster Plan, Infection Control Plan and Mitigation Plan. Fire extinguisher is fully charged and serviced within the last year. LPA noted during the last annual inspection that some of the facility contact information has not been updated and Executive Director agreed to submit an updated LIC200 to CCL to update facility phone numbers and facility email. Per conversation with Executive Director, she is in the process to obtain an Administrator certification. Executive Director agreed to submit updates of the following documents by 1/27/2023: LIC 308 Designated Administrator (if applicable), LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan (review and update if changes), Liability Insurance and lease agreement. No deficiencies cited during this inspection.