Facility Evaluation Report

Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager (LPM) Stephanie Cifuentes conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Shirley and LPM Cifuentes met with Director, Morgan Dye. The purpose of today’s visit was discussed, and LPA and LPM were allowed access to the facility grounds. The facility is licensed to serve 25 developmentally disabled clients ages 18, years and above. Facility approved for 15 non-ambulatory and 10 ambulatory clients.

LPA, LPM and Director Dye all toured the grounds of the facility. Facility is located in a single-story building, located in a commercial business area. LPA observed that the facility includes: a large multipurpose room, 2 restrooms, a changing room, relaxation room, music room, art room, storage room, two (2) staff offices, and one (1) Program director office, kitchen, and an indoor/ outdoor activity area. Documents are posted as mandated by Title 22 Regulations. Bathrooms are clean and operational. Toilets and water faucets worked properly; grab bars were secure, comfortable temperature was maintained in the facility.

All clients bring their own lunch. Hazardous items are inaccessible to clients and kept in a storage cabinet. First aid kit is fully stocked. Medications are centrally stored in a locked cabinet in the Program Director office. LPA observed three (3) fully charged fire extinguishers which were inspected.

LPA toured the kitchen area and observed refrigerator and on site washer/dryer.

During the visit, LPA and LPM observed infection control practices. LPA Shirley observed a sanitizing station at the facility entry with visitors logs and temperature checks. Sanitizer/soap, paper towels are in all the bathrooms and additional sanitation supplies are stored in staff office. LPA observed staff wearing masks and was shown isolation area. LPA observed trash cans with lids and required postings are throughout the facility. Emergency contacts updated and posted; PPE's are enough for 30 days.