Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen made 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 Human Resources Director Rocio Salcedo. LPA then met with Administrator / Program Director Kristen Hollobaugh, who arrived shortly after.

According to the facility license, the day program site has a maximum capacity for six (6) clients, of whom all must be ambulatory. Per LPA observation, LIC602 Physician’s Reports, and staff interview: During today’s inspection, there were a total of five (5) clients enrolled, and all were ambulatory. The day program did not have endorsements for delayed-egress doors or secured perimeter doors, and neither of these types of doors were present.

LPA interviewed multiple staff and performed a welfare check on all clients present. All clients that LPA met were non-verbal, but LPA saw that they were calm, clean, and safe. LPA also inspected the care records for all clients and the personnel and training records for multiple active staff. LPA toured both the interior and exterior of the day program facility, inspecting the activity room and all common areas. The day program’s facility was clean, sanitary, and in good repair. Doors, windows, toilet, shower, and lighting fixtures were all working. There was bottled drinking water available for client use. Pathways were free of obstruction and slip hazards. There was sufficient space to facilitate client learning/activities, meetings, dining, laundry, and visitation.