Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA met with the Case Manager, Yvette Sanchez, and explained the reason for the visit. The day program is licensed for 60 clients, ages 18-59, of which 6 may be non-ambulatory.

LPA toured the facility and inspected/observed the following using the Compliance and Regulatory Enforcement (CARE) tools.

Infection Control : The facility has sufficient supplies of PPE and utilizing gloves when necessary to assist the participants.. They are performing proper hand hygiene. Staff are cleaning and disinfecting surfaces regularly to keep the facility clean.

Physical Plant & Environmental Safety: The facility consists of the following: reception area, conference room, lockers, five (5) staff offices, four (4) restrooms, staff lounge, computer/library room, Media Room, Quiet Room, copy machine area, Art Room, kitchen, janitor's room, electrical room, exercise room, and two (2) storage rooms. The hot water temperature is measured within the required range of 105 - 120 degrees F. Knives and cleaning supplies are locked and inaccessible to participants.

Operational Requirements : The facility is operating within the approved fire clearance.

Staffing: The staffing is maintained at a 1 staff to 3 client ratio.

Personnel Records - Training: LPA reviewed 6 Staff records and they have the required documentation in their files. The CPR/First aid certificates are current.

Client Records - Incident Reports : LPA reviewed 5 Client records and files consist of the admission agreement, medical assessment with TB test result, consent forms, and current IPP or ISP.