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 Administrative Assistant Angelica Menes. LPA then met with Licensee/Administrator Dr. Ronald Fabian and Documentation Specialist Marlene Fabian, who arrived shortly after.

According to the facility license, the day program site has a maximum capacity for 112 clients, of whom 25 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 59 clients enrolled, of whom 15 were non-ambulatory, and none were bedridden. The day program did not have endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present.

LPA reviewed multiple client care records and multiple personnel files and training records. LPA interviewed multiple staff and interacted with multiple clients. LPA toured the interior and exterior of the facility, inspecting all classrooms and common areas. The day program’s facility was clean, sanitary, and in good repair. Doors, windows, toilets, shower, and lighting fixtures were all working. Pathways were free of obstruction and slip hazards. There was sufficient space and equipment to facilitate client learning/activities, meetings, meals, and visitation.

The facility’s ambient internal temperature was complaint at 73 F. Where tested, hot water temperature at taps accessible to clients were compliant in temperature: Activity Room Sink was 113 F, Bathroom #1 Sink was 111.2 F, and Bathroom #2 Sink was 110.5 F. [CONTINUED ON LIC 809-C]