Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced required Annual Inspection. LPA met with Program Manager, Simien Hires. LPA was accompanied by Program Manager 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 75 degrees fahrenheit. LPA inspected client activity rooms; they are equipped with required furniture and activity supplies 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 109 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. Day program does not administer medication and no medication is stored at the facility. LPA observed fire extinguishers, smoke alarms, carbon monoxide alarms, and first aid kit in the facility. The last fire drill was conducted on 8/14/23.

LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA observed the (C1) signature missing on the personal rights. Technical violation issued. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed (S1) missing orientation, employee rights and suspected abuse reporting from staff's file. Deficiency issued. LPA also observed criminal background transfer clearance missing for (S1). Deficiency with civil penalty issued.