Facility Evaluation Report

At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required - 1 Year Visit, and met with Administrator, Joe Cashel. Facility is an Adult Day Program that provides activities to Individuals with Disabilities. Facility has an approved fire clearance and capacity for 75 ambulatory clients, of which 30 clients can be non-ambulatory. Upon arrival, LPA was informed that there were currently 36 Clients at Day Program and 14 staff members on-site.

At approximately 10:10AM, LPA reviewed the Facility's Staff Roster and found that Staff Member 1 (S1) was not fingerprint cleared or associated to the facility as required. Administrator notified S1 to leave the premises (deficiency cited and civil penalty issued, see LIC809D and LIC421BG, Health and Safety Code 1522(c)(1)). At approximately 11:00AM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 4 activity rooms, 6 bathrooms and common areas. Facility has an Infection Control plan on file. There was an appropriate supply of cleaning products, hygiene products and paper products available for clients. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Per Administrator, clients bring their own snacks and lunches to program. Facility does not manage P&I monies. During walkthrough, LPA and Administrator observed the following to be unlocked and accessible to clients in care: Lysol disinfectant spray, biodegradable Tide Pods, and cleaning spray (deficiency cited, see LIC809D, regulation 82087(a)(3)).

LPA reviewed staff and client files, and client medications. Staff files were all found to be well organized, thorough and contained the required documentation, and had current First Aid and CPR certification. During client file review, LPA observed the following: 1 of 8 client files did not have an Admissions Agreement, 2 of 8 client files did not have a current Individual Service Plan, 5 of 8 client files did not have a Medical Assessment/Physician's Report, and 6 of 8 clients did not have proof of a negative TB test (deficiencies cited and technical advisories/violations issued, see LIC809D and LIC9102, regulations 82068(a), 82068.3(a), 82069(a), 82069(b)(1)).