Facility Evaluation Report

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Diane Figueroa (Assistant Program Director) and explained the reason for the visit.

The facility is an Adult Day Program (ADP) licensed to serve a capacity of 55 ambulatory developmentally disabled adults in the age range 18 and over, of which 25 may be non-ambulatory. The program consists of 1 large single-story building. A tour of the single-story building included: 4 staff offices, a conference room, lobby, 5 activity areas, 4 participants restroom of which 1 has a shower and 1 has a changing bed, 1 staff restroom, 1 nursing room, a relaxation room, and a kitchen area with a dining room.

LPA toured the facility with Diane Figueroa and the following was observed: facility is currently not serving any clients due to Covid-19. 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 under the kitchen’s sink. Facility has a locked closet with additional cleaning supplies. The facility has a fire sprinkler system in place and fire extinguishers were observed in each activity room. The restrooms were observed to be clean and have the required grab bars for non-ambulatory clients. The water temperature was tested in the participant's restrooms, in restroom #1 temperature was tested at 116.4 degrees F; restroom #2 was tested at 112.6 degrees F; restroom #3 was tested at 106.1 degrees F; restroom #4 was tested at 115.2 degrees F, which is within the required 105-120 degrees F. The program maintains a comfortable temperature in each room/office. The First Aid kit was observed in the nursing room and it is fully stocked with all required items including a current manual. Facility kitchen area has medication closets that will be kept under lock. The kitchen area has a refrigerator where the clients can store their food. Sharps are kept locked above the kitchen's sink. The last fire/emergency disaster drill and earthquake drill was done on 08/01/2022. Food supplies were not observed because clients will bring their own food from their homes. Client medication and files were not reviewed as there are no participant at this time. (CONTINUED TO LIC 809C)