Facility Evaluation Report

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection. LPA identified herself to day program manager (PM) Sheila Norris who was advised of the purpose of the visit. The facility is currently licensed as an Adult Day Program and has 10 clients present.

LPA Bueno and PM Norris toured the facility. The facility has no bodies of water. LPA and PM observed that client access doors are unlocked and free of obstruction. The facility has a working telephone for use. The facility fire extinguishers were last inspected on 10/25/23. The fire alarms are maintained and tested by a third party service provider. During today's visit, the carbon monoxide detector was installed. The last fire and earthquake drill was conducted on 11/28/23 and flood drill was completed on 10/26/23.

The following were observed of the physical plant:

LPA Bueno and PM Norris observed all activity rooms were kept clean and free from odors. Hazards were kept safe and secured from clients. Activity rooms had appropriate seating and tables for activities for all clients served. LPA and PM observed clients participating in activities while maintaining appropriate staffing within each group. LPA Bueno observed a kitchen with a refrigerator and several storage cabinets. The facility provides snacks. Restrooms were clean and toilet paper, paper towels and soap is present in each. Three bathrooms were inspected by LPA Bueno and PM Norris. A complete first aid kit was observed. The facility does not maintain any medication nor does it use manual restraints. Toxins, cleaning agents, and other supplies are kept locked and secured.

LPA Bueno inspected client files and found that required documentation including clients' rights, admissions agreement, and Individual Service Plan (ISP). LPA reviewed staff files were inspected which contained background clearance, First Aid/CPR certification, and required training. An exit interview was conducted where this report was discussed with provided to PM Norris at the conclusion of the inspection.