Facility Evaluation Report

Licensing Program Analysts (LPA) Dang Nguyen and Hannah Rodgers conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Nicole Guibert.

According to the facility’s license, the day program facility has a maximum capacity of forty-five (45) clients, of which five (5) may be non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of forty-one (41) clients enrolled, of whom one (1) was non-ambulatory and none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and none of these were present.

LPAs, accompanied by Licensee’s staff, also toured the interior and exterior of the facility and inspected all common areas and classrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Doors, windows, sinks, and toilets were working. There were no sharp objects, toxic chemicals/poisons, or other hazards accessible to clients. Extra hygiene supplies and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate meals/snacks, visitation, meetings, and client activities.

LPAs observed, and manager interview confirmed, that the day program did not have carbon monoxide alarms installed, as required. Where tested, hot water temperature at two (2) of four (4) taps accessible to clients were too hot: Common Area Sink was 127 F and Break Room Sink was 122 F. However, the sinks in the public restrooms were complaint in temperature: Bathroom #1 Sink was 115 F and Bathroom #2 Sink was 113 F. The facility’s ambient internal temperature was complaint at 75 F. Appliances to preserve perishable food were also all compliant in temperature: Both refrigerators were 40 F, and Freezer was 0 F. Food that was present was safely stored. [CONTINUED ON LIC 809-C, 1 of 2]