Facility Evaluation Report

Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced required annual (mitigation) inspection. LPA was greeted and granted entry and completed the Coronavirus 2019 (COVID-19) screening procedure. LPA met with Program Manager (PM) of the Adult Developmental Program, Atram Behmanesh, and PM of the Day Training Activity Center (DTAC) Pala, Chelsae Mansfield, who joined shortly around 9:25 am. LPA stated the purpose of the visit, and LPA and PM of DTAC Pala conducted a tour of the first floor of the facility which is one out of the three programs that is solely licensed with the Department.

During the inspection, LPA observed 43 clients on site as the remaining clients were on a hybrid schedule learning from home. LPA observed 13 staff present wearing PPE. LPA inspected common areas, storage areas, activity rooms, offices, and bathrooms. All areas were clean and organized and found no health and safety issues. Hot water was measured at 111.3 degrees Fahrenheit in Bathroom #1, 105.8 degrees Fahrenheit in Bathroom #2, 111.5 degrees Fahrenheit in the Break Room, and 112.8 degrees Fahrenheit in the Activity's Room sink. LPA observed the facility had sufficient PPE supplies over 30 days’ worth, cleaning, and incontinence supplies all of which were properly locked and stored. LPA and PM spoke to Maintenance Supervisor (MS) Romaldo Escobedo and reconfirmed that the testing of the smoke detectors require a special tool maintained by the Bay Alarm Company. Upon record review of the their last fire inspection completed on 05/25/21, DTAC Pala did not pass two out of the five tests. Per MS, the smoke detectors were replaced on their last quarterly inspection on 03/21/22. Medications, cleaning supplies, and sharp items were inaccessible to the clients in care except for the glass cleaner observed in the bottom cabinet of the Employee Lunch Room where the clients would participate in cooking activities. The glass cleaner was removed during the visit. The fire extinguishers were mounted and charged. LPA provided a technical assistance to update the Emergency Disaster Plan for Adult Day Programs (LIC610D) and to post a copy in a prominent place by the entrance, and to post the COVID-19 precautionary signs by the entrance as well. LPA reviewed the approved COVID-19 mitigation plan.