Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Tonya Danielly.

The facility is licensed for a maximum capacity of 12 clients, 2 of which may be non-ambulatory. During today’s visit, the facility had a census of 11 clients, all of which were ambulatory. The Administrator for the facility is Tonya Danielly and their certificate was valid and current.

During today’s visit, LPA toured the facility and inspected each room of the facility, including rooms for client use, bathrooms for client use, kitchen, and outside space. No bodies of water were observed near or on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. Interviews with the staff and Administrator, as well as LPA observation revealed that a child day-care facility is operated on the property and both populations were present at the same time during LPA's visit. Interviews with facility staff revealed that the most recent fire clearance inspection was conducted on 9/22/2022 and approved the facility for 12 adult clients. Previous fire clearance was approved for 48 children. Per Administrator, around June 2023, the facility swapped rooms for the childcare facility and the adult day program facility without updating facility fire clearance for changed population types. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 66.5 degrees Fahrenheit in a client bathroom. Per Administrator, clients do not have access to hot water for handwashing or grooming purposes. The facility’s internal temperature was measured at 70 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for client medications and client and staff files. Staff present at the facility during the time of the inspection had a criminal background clearance, however, Staff 1, Staff 2, Staff 3, and Staff 4 (S1-S4) were not associated to the facility. Interviews with the Administrator revealed that S1-S4 had been working at the facility for more than 5 days.