Facility Evaluation Report

Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct a required annual visit. LPA met with Program Manager Marissa Velazquez who was informed of the purpose of the visit.

A tour of the facility was conducted and LPA observed the facility is made up of multiple classrooms and activity rooms, multiple bathrooms, two (2) offices, storage rooms, kitchen, and changing room. LPA observed clients engaging with staff in the activity rooms as they prepared to go home for the day.

LPA observed the facility is clean and physical plant is in good repair. The facility has multiple fire extinguishers charged and mounted throughout the facility. Carbon monoxide and smoke detectors were tested and found functional. LPA reviewed random staff files and found that staff had a criminal background clearance on file, updated training, and had current CPR/First Aid and CPI training. LPA reviewed random client files and found that files had updated Individual Program Plans (IPP) and Physician's Report along with signed admission agreements. The facility provides snacks for clients. LPA observed the kitchen area to be clean and snacks stored in a safe and healthful manner. Cleaning solutions are secured in locked storage rooms. The hot water in facility bathrooms met department requirements. The facility has one (1) client who requires medication and the medication is centrally stored and locked in a cabinet located in a staff office.

LPA reviewed the facility's emergency and disaster plan and infection control plan. Facility conducted their last fire drill on 07/30/2024 which met the department requirements. LPA observed emergency supplies and first aid kit with all required items. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Program Manager Velazquez.