Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Montrey Vaughn, Program Coordinator and explained the reason for the visit.

The facility is licensed as an adult day program to serve a total of 40 ambulatory and 35 non-ambulatory developmentally disabled clients between the ages of 18 to and 59. The facility is located in the back of a church and it consists of: lobby/history room, main hall (activity room), kitchen, 2 bathrooms containing various stalls and sinks, a sensory area, administrative/staff office, nurse office, copy room, participant and staff locker room and a changing room.

LPA toured the facility with Montrey Vaughn, Program Coordinator and observed the following:

Facility is in good repair indoor and outdoor. The activity room has different tables and chairs for participants to work in groups. Sufficient staff was observed. Kitchen is not used to prepared meals unless they are having an activity. Refrigerator used to store participants meals was observed clean. Changing room, and bathrooms were observed clean and in working order. Woman's restroom sink has accumulation of hand soap on a part below the sink. Water temperature was tested in each available sink and tested between 101.6 – 137.9 degrees F., which is not within the required 105-120 degrees F. Facility has smoke/carbon monoxide detectors in the main hall, nurse office and lobby area. Two smoke/carbon monoxide detectors did not operate when tested. One in the main hall and one outside the changing room. Cleaning supplies were locked in a closet near the changing room.

LPA reviewed 5 participant and 5 staff files.

Emergency disaster plan was reviewed, and last Emergency/Disaster Drill was conducted on 10/02/24. Fire extinguishers were lasted checked on 6/05/24 and 9/18/24. The emergency disaster plan need to be update.

Deficiencies were noted during this visit. Technical Advisory provided.

Exit interview was conducted with Montrey Vaughn, Program Coordinator and a copy of this report was provided along with appeal rights. .