Facility Evaluation Report

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with the Administrator Lisa Ann Williamsen and explained the reason for the visit. The day program’s clients/consumers are community based. No clients/consumers were observed on the day of the visit. The day program is operating it's normal hours for consumers of 8:00 a.m. to 2:00 p.m.

The LPA and the Administrator toured the physical plant areas inside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: The LPA observed the conference/rest area to be clean and properly furnished. KITCHEN: The LPA observed the kitchen area/ staff room. Cleaning solutions, toxins, chemicals and other hazardous items were inaccessible and locked away in the staff room/ kitchen. The clients/consumers do not have access to the kitchen area. The hot water measured at 112.3 degrees Fahrenheit. The LPA observed the fire extinguisher to be fully charged and last serviced on 11/03/2023.

CLASSROOM/OFFICES: The LPA observed offices and the classroom, which were observed to have the required furniture and supplies. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms were observed to clean and sanitary and in operating condition. The hot water measured at 111.8-degree Fahrenheit. Signs are posted throughout all four (4) bathrooms to promote hand washing.

OUTDOOR SPACE: Passageways to the lobby on the second floor were free and clear from obstruction.

RECORD REVIEW: Consumers’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. INFECTION CONTROL: The LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient.

No deficiencies were observed at this time. Exit interview conducted. A copy of the report was issued.