Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The day program’s facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Program Administrator Susana Levack.

According to the facility license, the day program site has a maximum capacity for 186 clients, of whom 50 may be non-ambulatory, but none may bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of 131 clients enrolled, of whom 26 were non-ambulatory, and none were bedridden. The day program did not have endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present.

LPA reviewed multiple client care records and multiple personnel files. LPA interviewed multiple staff and multiple clients, and toured the interior and exterior of the facility, inspecting all classrooms and common areas. The day program site was clean, sanitary, and in good repair. Doors, windows, toilets, shower, lighting fixtures, and drinking water dispensers were all working. Pathways were free of obstruction and slip hazards. There was sufficient space to facilitate client learning/activities, meetings, dining, and visitation.

The facility’s ambient internal temperature was complaint at 73 F. Where tested, hot water temperature at taps accessible to clients were compliant in temperature. Refrigerators and freezers used to preserve perishable food were complaint in temperature. There were snacks available for those clients who forget to bring their own lunch from home. Disposable plates and cutlery were present. There was a locked area for storage of medication. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C, 1 of 2]