Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced required Annual Inspection. LPA identified herself to Day Program Case Manager, Tammy Higgins who was advised of the purpose of the visit. The facility is currently licensed as an Adult Day Program and has 49 clients present. LPA was accompanied by Case Manager, Tammy Higgins and Lead Program Aide, Kara Mitchell to conduct a general overall inspection, which included, but was not limited to, the following:

LPA inspected the facility inside and outside. LPA observed all passageways are clear of obstructions. The facility is maintained at a comfortable temperature of 71, 72, 70 and 71 degrees fahrenheit. LPA inspected client activity rooms in wing A, wing B, wing C and the gym; they are equipped with required furniture and activity supplies/equipment for clients. LPA inspected client bathrooms; bathroom appliances were operating in good and sanitary conditions. LPA observed grab bars in the bathrooms. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 107.1, 108.2, 110.4, and 108.7 degrees fahrenheit. Disinfectants, toxins, sharps and cleaning supplies are locked and inaccessible to clients. There are no firearms/ammunition or bodies of water.

At Day Program, clients are responsible to bring their own lunch. Snacks were accessible to clients and stored in a healthful manner. LPA observed the kitchen area to be clean, free of odors, and in a healthful manner.

LPA observed sufficient staff present for the number of clients in care. Medication is locked and inaccessible to clients in the facility. LPA observed fire extinguishers, smoke alarms, carbon monoxide alarms, and first aid kit in the facility. The last disaster drill was conducted on 2/26/24.

LPA reviewed six (6) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files along with the administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.