Facility Evaluation Report

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced annual inspection and met with Pat Ball, Director, to discuss the purpose of the visit.

The program provides services to developmentally disabled adults ages 18 to 59 and is licensed to serve 27 non-verbal clients with developmental disabilities and restrictive health conditions. At the time of the inspection, 23 clients were participating in the program. Surveillance cameras were observed in the exterior areas of the facility. The facility does not handle or store client medications, including PRN medications.

The program operates in a single-story building consisting of two (2) offices, including a nurse's office; two (2) bathrooms; one (1) large activity room with a kitchen area utilized for cooking classes; and three (3) additional rooms designated for physical therapy, relaxation activities, and creative activities.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools during the inspection and observed the following:

Five (5) staff files were reviewed and included criminal background check clearances, educational qualifications, required training certificates, CPR/First Aid certifications, and TB screenings. All records reviewed were found to be compliant at the time of the inspection.

LPA reviewed seven (7) client files. Records reviewed included Admission Agreements, Individual Program Plans (IPPs), Needs and Services Plans, and TB documentation. During the review, LPA noted that IPPs were not available for Clients C1, C3, C6, and C7. All other records reviewed were found to be compliant.