Facility Evaluation Report

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced required visit to the facility for the purpose of an annual inspection. LPA met with Program Director Kris Kacirek was informed of the purpose of the visit. At the time of the visit there was seven (7) staff and thirty-six (36) clients present.

LPA toured the facility inside and out and conducted staff and client interviews. The facility has no bodies of water or firearms and ammunition on the premises. The facility has multiple charged fire extinguishers and operating fire alarms/carbon monoxide detectors. Director Kacirek stated the fire department inspects their facility annually. Outdoor and indoor passageways were kept free of obstruction. Outdoor activity space was free of hazards and had shade cover for the clients. Cleaning supplies, medications, and the sharp and dangerous objects were kept locked and inaccessible to the clients. Facility has the proper staff to client ratio as required by Title 22 regulations.

Centrally stored medications are kept in the office and is locked in a cabinet. The facility currently dispenses medications for two (2) clients. LPA reviewed client medications for two (2) clients and found all medication listed on MARS and all required labeling was found to be in place.

LPA observed safe and healthy indoor activity space for the clients. LPA observed designated areas and classrooms where activities such as music, fitness, arts and crafts, computer lab, sensory room, and zoom classes take place. LPA also observed isolation and changing rooms. LPA toured the kitchen area. Clients bring their own food for both snacks and lunch but the facility provides snacks and emergency food for the clients if needed.