Facility Evaluation Report

At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Chief Operating Officer (COO), Daniel Swearingen and Office Manager (OM), Rhoda Robertson. Facility is an Adult Day Program for high functioning clients/students, and has an approved fire clearance for 30 Ambulatory clients. Upon arrival, LPA was informed that there were 4 clients attending program and and 7 staff members on-site. LPA was informed that all clients at program for the day were out of the community on a group walk.

At approximately 9:35AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:40AM, LPA conducted a walk through of the facility with the OM. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control Plan on file. Facility has three activity rooms, a kitchen, a large work shop, a supply room for toxins and art supplies, and office spaces. Clients have access to the three activity rooms. Clients do not enter the work shop, kitchen, or supply room without staff supervision. Clients do not enter staff office spaces. Clients manage their own monetary funds, medications, transportation, and bring their own snacks and lunches to program.

Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. During walkthrough, LPA observed that some food containers were not labelled with the open date in the facility kitchen area. LPA discussed with OM and COO about labelling food containers in the facility fridge with the open date.

LPA reviewed staff and client files. Staff files were all found to have current First Aid and CPR certification. LPA discussed with OM on ensuring that there is documented proof of training for all facility staff upon hire and annually. Per OM, they conduct a lot of hands on training/shadowing for their facility staff. 1 of 5 client files were found to have a incomplete medical assessment. 2 of 5 client files were observed to have Admissions Agreements signed by the client but were missing signatures from the Licensee and Authorized Representative. All client files had updated appraisals.