Facility Evaluation Report

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Danielle Berger Licensee and explained the reason for the visit.

The day program is licensed to serve 67 ambulatory and 8 non-ambulatory adults. The day program consists of one single story building comprised of multiple small rooms used as office space or to conduct activities. There is a large activity room in the center of the building and a kitchen.

LPA conducted a tour of the facility with Susan Lujan - Staff and observed the following:

Facility is in good repair inside and outside. The outdoor space provides a shaded basketball court, and shaded sitting area. The main room provides areas for activities. The small rooms are set up for learning activities. There are two restrooms inside and three outdoors in working condition and water temperature tested between 114.6 - 118.7 degrees F., which is within the required 105-120 degrees F. Emergency kit was observed and has the required items. Fire sprinkle system and fire extinguishers were observed throughout the building. Fire extinguishers were last checked on 7/30/23. Kitchen has a refrigerator to store snacks and or food that requires refrigeration. Cleaning supplies and knives are kept inaccessible to the clients in the kitchen. LPA reviewed Safety Compliance Report, Inspection and Testing Form (fire alarm), and Infection Control Plan.

LPA reviewed files for 4 clients and 4 staff. clients#1,#2,#4 (C1,C2,C4) did not have an admission agreement in their file. LIC 610D (10/03) was reviewed.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Susan Lujan Staff and a copy of this report, LIC 809D, and appeal rights were provided.