Facility Evaluation Report

On 11/17/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Kelly Mckenna-Director. The facility profile shows that the facility is licensed for a capacity of (40) clients, of which (5) may be non-Ambulatory. The director stated that the facility has (10) clients enrolled in the program. The total number of non-ambulatory clients attending the program is (10). The staff-to-client ratio is (1) staff to (3) clients. Director stated that the facility has (0) clients with a Restricted Health Care condition. Currently, there are (3) clients using protective or assisted devices. The facility conducted a fire drill on 11/6/2023, and a Disaster Plan was on file. The last inspection held by the fire department was on 10/27/2023. The program does not provide transportation.

LPA Iniguez and Director toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. The (2) bathrooms are clean and operational. No firearms are stored at facility and no bodies of water present. Medications are not kept in the facility. Facility does not provide food for clients; clients bring their own lunch.

As a part of today's inspection, LPA reviewed (4) client records, (3) staff records, and medications and inspected the entire facility inside and out. LPA and Director toured the entire facility. All records were maintained properly.