Facility Evaluation Report

Licensing Program Analyst (LPA) Edward Tapia conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA met with Regional Director Mandy Speakman and stated the purpose of the visit.

The facility is licensed for fifty non-ambulatory clients. This is an Adult Day Program.

At about 1:00 pm, LPA was informed that all managers were in a meeting. At 1:30 pm, Regional Director assisted LPA with a tour of the facility. The facility currently had 7 clients in the day program. LPA was informed that most program services are provided out in the community. LPA observed clients and staff throughout the facility. LPA observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting the results. The facility contained program rooms, office spaces, a computer room, a kitchen, dining area and quiet rooms. Sharps and cleaning supplies were inaccessible to clients in care. LPA observed required department postings, Covid-19 precautionary postings in the facility as well as hand washing signs in all restrooms and hand washing areas. All restrooms were observed to have ample supply of soap and appeared to be clean. All common spaces of the facility were observed to have all the required components. Facility has a back-up emergency food supply as well as PPE supplies.

LPA toured the outside of the facility and observed a shaded seating area. LPA was provided with a notice of fire inspection completed on 10/12/2021. LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility.

For this visit, no deficiency was noted in areas observed.

LPA Tapia conducted an exit interview with Regional Director Mandy Speakman and copy of this report was explained and left at the facility.