Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with Susan Lujan, the Administrative Assistance. The purpose of the visit was explained. The day program is licensed to serve 67 ambulatory and 8 non-ambulatory adults.

LPA Chan toured the facility and observed the following:

* The day program consists of a single story building comprised of 2 offices, the main activity room, a meeting room, storage supply rooms, arts & craft room, math room, kitchen, staff break room, and 2 bathrooms. There are 3 additional restrooms in the back area along with a large recreational space. There are several tables outside with shades and a garden area. There is a log cabin used as storage and inaccessible to clients. LPA did not observe any obstructions to the walkways nor any bodies of water.

The knives and cleaning products are stored and locked in the kitchen under the sink. The hot water temperature was measured at 133 degrees F, which was over the required range of 105-120 degree F.

LPA reviewed (3) personnel files. Files are complete and staff have current CPR & First Aid certificates. LPA reviewed (5) client files. Client files have the required documents. The day program does not administer routine medications to the clients, except for PRNs when needed.

Facility has the updated Emergency Disaster Plan and is reviewed annually by the licensee. Drills are being conducted every other month.

A deficiency was issued today. Exit interview was held and a copy of this report was given to S. Lujan.