Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez conducted the unannounced annual inspection. LPA met with Administrator, Noey Garcia, and explained the purpose of the visit. The day program is approved to serve 145 adults, of which 45 may be non-ambulatory.

LPA toured and inspected the facility using the CARE tools. The following were observed:

The day program consists of a main building with administrative offices and staff lounge and additional classrooms located to the rear. They are currently utilizing 7 classrooms to conduct activities with the participants. The middle building is being used as storage. There are communal bathrooms for clients to use in each building. The hot water temperature was measured within the range of 101.1 – 131.2 degrees F which is not within the required range of 105.0 -120.0 degrees F. There are no obstructions to the walkways and the facility is clean. Disinfectants and cleaning solutions are locked. The fire extinguishers were last inspected on 09/2023

LPA reviewed 4 personnel files. The site coordinator and staff have the annual training hours and health screening forms along with TB test results but were not at the facility. They all have criminal background clearance and associated to the facility. LPA reviewed 4 Client files. The files consist of the admission agreement, IPP/Appraisal Needs & Services Plan, and medical assessment with the TB results. All IPP needs updating. There is one client who is taking routine medication during the program hours and it is documented when given. There are 5 clients that have PRN medications at the program but do not have PRN authorization letters. The medication is centrally stored and locked in the main office. The clients bring their own lunches and are not provided by the program.

The facility has the Emergency Disaster Plan with relocation sites, shutoff valves, and local emergency contact numbers but needs to be updated.

There are deficiencies issued today and technical advisories issued. An exit interview was held and a copy of this report was given to Noey Garcia along with appeal rights.