Facility Evaluation Report

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced annual visit at the facility which included the following domains:

Infection Control, Physical Plant and Environmental Safety, Operational Requirements, Staffing, Personnel Records- Training, Client records- Incident Reports, Client rights- Information, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness.

LPA Trueman met with Administrator Ellisset Ramirez and explained the reason for the visit.

The facility is an Adult Day Program (ADP) licensed to serve 50 clients, of which 10 may be non-ambulatory, ages 18 and over. The program consists of: Resting Area, Television Room, Art Room, Dining Room, Kitchen, Computer Room and Waiting Room.

LPA toured the facility and the following was observed: There were 35 clients at the facility during the visit. The program site is clean, safe, sanitary and in good repair. All passageways are free from obstruction. Disinfectants, cleaning solutions and poisons are inaccessible to clients and are locked. The restrooms were observed to be clean and have the required grab bars for non-ambulatory clients.

Licensee maintained an individual admission agreement for each client.

The program maintains a comfortable temperature in each room/office.

The First Aid kit is kept and it is fully stocked with all required items including a current manual. Food is not prepared at this program and clients are able to bring their own food.

Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.

Medication is not administered at program.

5 staff files and 5 client files were reviewed.

Interviews were conducted with 4 Staff and 4 Client's.

No deficiencies. Exit interview conducted.