Facility Evaluation Report

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that twenty (20) clients attend this day program at this facility. However, there were zero (0) clients present during the inspection, due to this being a community-based day program. There was four (4) staff members present. The Director II, Vanessa Englefield and Program Coordinator, Alicia Rivas was advised of the annual and conducted and completed the facility tour.

Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, IPP, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/ Staffing/ Administration : LPA reviewed employee records. Five (5) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Administrator, Alicia Rivas’s training hours.

Food Service: Food prep areas are clean and organized. There was emergency food and water supply is present. There were no sharps located in the facility.