Facility Evaluation Report

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Assistant Program Director, Neil Makwana, who assisted with visit. The facility is a day program and licensed to serve sixty (60) Developmentally Disabled of which fifty (50) ambulatory and ten (10) non-ambulatory clients. Facility licensing fees are current. There are currently 11 clients at the facility during the visit and total of 40 clients on roster.

During the visit, the infection control domain tool was used, a tour of the facility was conducted and medication was reviewed. Facility does not provide daily snacks or meals at the day program.

LPA observed the facility is a single story building located in a commercial business area. The facility consisted of a Reception area with Case Manager office space, a Janitorial room, Chef room (Client's kitchen), Staff Lounge, Canvas room, Pulse room/ Computer Lab, Staff kitchen, Laundry room, Serenity (Relaxation) room, Einstein room, Core room, Basics room, Evolve room, Media room, Program Directors office, Behavioral Consultant office, Conference room, Human Resource office, four (4) restrooms, and a shaded area with chairs provided in the rear and indoor/ outdoor activity areas. Water temperature in the bathroom is measured at 118.5 degrees Fahrenheit and toilets observed operable. Medications are centrally stored, locked and maintained in the Media room. Medication records are current. Facility smoke detectors and carbon monoxide devices are operable, fire extinguishers’ last service date is 01/05/22, disaster drill is conducted on 03/18/22, first aid kit is fully stocked with all required items, cleaning supplies and other toxins are locked in a storage room. All rooms have required furniture and equipment necessary to conduct all activities. Signages and mandated documents are posted. Sharp knives and objects are locked and inaccessible to clients. All clients bring their own lunch, however, facility has back-up food and snacks. Snack is stored, prepared, and served in a safe and healthful manner. Facility has plenty of water available for clients. Hazardous items are inaccessible to clients.

No deficiencies was cited. Exit interview was conducted and a copy of this report was provided