Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual Inspection, utilizing the inspection tool. LPA met with Day Program Manager and explained the purpose of the visit.

Facility has capacity for 43 participants, which 14 may be non-ambulatory. Today's visit, LPA counted 15 participants in care; however, five were located outside in the garden area. Day Program Manager stated participants are in session rotations to ensure facility remains in compliance. LPA advised Day Program Manager to develop a participant session plan to identify the participants that are non-ambulatory to ensure facility remains compliance to fire clearance.

LPA and Day Program Manager conducted an inspection of the interior and exterior of the facility including the common spaces, Multi purpose rooms and bathrooms, activity/exercise rooms, group conference rooms, music room, the kitchen, and the outside garden area. Fire extinguishers present with current service tags. LPA observed facility to be free of sharps, toxins and dangerous items for participants in care. LPA observed sensory room to now be a staff office. LPA informed Day Program Manager to submit LIC 200 and updated facility sketch for a new fire inspection.

LPA reviewed documentation of fire drills to be conducted monthly.

In the areas that were evaluated, no deficiencies were observed.

Exit interview conducted and a copy of report was provided.