Facility Evaluation Report

On 10/23/2024 at 9:12am, Licensing Program Analysts (LPA) Zina Brown made an unannounced visit to the above facility. The purpose of today's visit was to conduct an annual inspection of the facility. On today's visit LPA met with facility Mark Arellano (Site Mananger). The facility profile shows that the facility is licensed for a capacity of (60). The Program Director stated that the facility has (15) clients currently enrolled in the program: (13) ambulatory and (2) non-ambulatory. The staff to client ratio is (1) one staff to (3) three clients. Site Manager stated none of the clients have restricted health care conditions or utilize any protective devices. The last disaster drill was conducted 10/17/2024 and a Disaster Plan is on file. The last inspection held by the fire department was on 04/15/2024. The program does not provide transportation.

As a part of today's inspection LPA reviewed (10) client records, (6) staff records, and inspected the physical plant. This is a day program located in one large building consisting of the following: a parking lot (drop off/pick up area), lobby area, 5 classrooms (gym area, art room, game room, music/quiet room, computer room), a cafe area with a refrigerator, stove, and sink (water tested at 108.8 F) with dining area and houses an enclosed washer and dryer area, storage/supply room, administrative offices, 2 bathrooms (men’s and women’s), outside shaded area, and gated driveway.

At 9:45am, LPA conducted a tour of the physical plant with the site manager and observed the following: walls and floors were in good condition, adequate lighting and fire extinguishers were properly charged. LPA observed plenty of storage space and chemicals were properly locked. The restrooms were clean and within Title 22 regulations. The kitchen was clean and a refrigerator was available for client use. The day program does not provide lunch however provides snacks on occasion to clients. The first aid kit was available and fully stocked. The walkways throughout the day program and all exits were clear of hazards and debris.

LPA observed the following not in compliance: On 10/23/2024, LPA conducted a file review of the 7 out of 10 client files and did not observe an Needs and Services Plan within 30 days after admission date.

Deficiencies Cited Under California Code of Regulations Title 22, Division 6, Chapter 3.

Exit interview conducted and a copy of the appeal rights were given.