Facility Evaluation Report

Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Assistant Director of Day Programs Mark Fisher and Director Debra Emerson.

According to the facility’s license, there may be a maximum of four hundred (400) developmentally disabled adults at any given time at the day program site, fifty (50) of whom may be non-ambulatory. During today’s inspection, there were fifty-six (56) clients present at the day program site, of which six (6) were non-ambulatory. The facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by the Director of Operations Laura Shanahan, toured the interior and exterior of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Doors, windows and screens, sinks, and toilets were in working order. Hand hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate meetings and client activities. The facility’s ambient internal temperature was comfortable and compliant, at 72 F. Hot water temperature at taps accessible to clients were also compliant: Kitchen Sink #1 was 115.2 F, Women’s Public Restroom Sink was 107.8 F, Men’s Public Restroom sink was 107.5 F. Some consumers take medications (prescription and PRN) at the program, LPA inspected the medication room and found that medications were properly labeled and stored in locked areas. The facility maintains a medication log which LPA also reviewed.

The facility's swimming pool was fenced in compliance with Regulations. Per the Health and Safety Manager Kim Holt, the swimming pool is inaccessbile to clients unless there are two (2) aquatic guards (licensed life guards) present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters