Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced required Annual Inspection. LPA identified herself to Administrator, Therese Kragness who was advised of the purpose of the visit. The facility is currently licensed as an Adult Day Program and has 68 clients present, 6 remote and 10 absent. LPA was accompanied by Administrator 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 72, 72, and 74 degrees fahrenheit. LPA inspected client activity rooms; 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 109 and 109.8 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 are made available. LPA observed the refrigerator not maintained in sanitary conditions where 3 dozen of expired eggs and moldy cheese was found. Deficiency issued.

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 6/5/23. Deficiency issued.

LPA reviewed six (6) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed five (5) staff files along with the administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.