Facility Evaluation Report

Licensing Program Analysts (LPA) Sanjay Vaid conducted the required annual inspection using the CARE tool. LPA met with Program Director, Michael Santos, and explained the reason for the visit. The day program is licensed for 60 clients, ages 18-59, of which 15 may be non-ambulatory. Today’s census is 35 clients.

LPA toured the facility and inspected/observed the following:

Infection Control: The facility has sufficient supplies of PPE and utilizing gloves when necessary to assist clients. They are performing proper hand hygiene before and after caring for clients and providing snacks. Staff are cleaning and disinfecting surfaces regularly to keep the facility clean. Physical Plant & Environmental Safety: The facility consists of 2 main rooms, 3 administrative offices, receptionist room, 6 activity rooms, 4 restrooms, conference room, kitchen, and 2 storage rooms. The facility is clean, sanitary, and in good repair. Disinfectants and cleaning solutions are properly stored and locked. The hot water temperature is measured within the required range of 105 - 120 degrees F. Operational Requirements: The facility is operating within the approved fire clearance. Staffing: The staffing is maintained at a 1 staff to 1 client ratio for 28 clients, 2 staff and 1 client for one client and three clients have 1 staff to 2 clients, the staffing ratio depends upon the clients’ needs and behavioral support. Personnel Records - Training: LPA reviewed 4 Staff records, and they have the required documentation in their files. The CPR/First aid certificates are current. Staff receive ProAct training annually. Client Records - Incident Reports: LPA reviewed 3 Client records and the files consist of the admission agreement, medical assessment with TB test result, consent forms, and current IPP or ISP.