Facility Evaluation Report

On 3-18-2025 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the program director Candice Pelletier and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the classroom areas, resident bathrooms, common areas, kitchen area, breakrooms, storage areas, office spaces, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an adult day program with a current census of 125. Facility has 4 classrooms and 4 bathrooms for client use. There are additionally 8 offices available for staff use, and a changing room. LPA also conducted the inspection using the CARE tool. The facility has an approved infection control plan in place.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 70*F. Client classrooms were sanitary and had the required furniture and furnishings and other supplies necessary to conduct the program. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 11-26-24. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to clients in care. Medication storage area was observed to be locked and inaccessible to clients in care. First aid kit was observed to have adequate supplies and accessible to staff.

During this inspection 5 client files and 5 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. Client files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s surety bond is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights posted. Facility has appropriate internet access available for resident use. {Cont. on 809C}