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 Monica Valencia and explained the reason for the visit.

The purpose of the visit is to conduct the Annual Inspection.

The program is housed in a commercial area, with its own parking lot and consists of a single story structure with a reception area, three offices, eight program breakout rooms, changing room, locker area for client personal storage, kitchen, staff break room/kitchen, washer/dryer room, two bathrooms and a shaded patio area. The program is equipped with air conditioning. There are no bodies of water or fireplaces. Shaded patio area is gated and safe from traffic

LPA toured the facility and the following was observed: There were 17 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. 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 bring their own food.

Medication was administered per physician's directions. Medication was reviewed for 4 client's.

Interviews were conducted with 4 client's and 4 staff.

5 staff files and 5 client files were reviewed.

No deficiencies. Exit interview conducted.