Facility Evaluation Report

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control. LPA Flores met with Cheryl Jackson Staff and explained the reason for the visit. Mark Hamilton Director arrived 30 minutes later.

The facility is licensed as an Adult Day Program for adults between the ages of 18 and over who are developmentally disabled, for a capacity of 60 consumers (10 adults may be Non-Ambulatory). The staff to client ratio is 1 caregiver to 3 consumers. The facility consists of a bakery, isolation room, activity room and a craft room.

LPA Flores and Cheryl Jackson Staff conducted a tour of the facility and observed the following:

Lobby/entrance area has a table set up. No sign in log, or thermometer was observed. Upon review of logs last screening was conducted on 10/14/22. Craft room is set up for 3 people at a time staff was observed wearing a face mask. Activity room was observed set up with a large table, no social distancing was observed between clients, staff were not wearing face masks. Set up area was observed and cleaning supplies were kept inside a metal prep storage unit which does not have a lock, water temperature was tested at 87.4 degrees F. Bathrooms were observed in working condition and water was tested as follow: Bathroom #1(B1) water temperature tested at 89.7 degrees F. and Bathroom #2(B2) tested at 87.8 degrees F. which is not within the required 105-120 degrees F. No hand washing signs were observed or paper towel available. Outdoor area has shaded area and sitting area, to the right of outdoor area a table a hose, basket, turf, two mop buckets, and metal box were observed. Bakery/kitchen area was observed upon entrance a machine on the ground was observed to be in the process of repair which can be a hazard to clients in care. Two staff bathrooms were observed no hand washing signs available. Isolation area is missing storage area with PPE supplies and a trash can for disposing PPE. Kitchen staff were not wearing face mask while preparing food items. Storage area was observed unlock during the visit director attempted to closed lock and was unable to lock, no disinfecting supplies were observed. (CONTINUED ON LIC 809C)