Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection on 1/16/2025. LPA met with explained the purpose of the visit.

Facility is a 48 capacity senior adult activity day program with a current census of 19. The staffing ratio is 7 to 1. The facility has one large area designated for client use and program activities. Tables in the classroom were observed to be socially distanced. LPA also conducted the infection control domain tool. The facility has an approved COVID Mitigation plan in place. LPA and Karla inspected the physical plant including but not limited to the kitchen, bathrooms, large activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was measured at 118 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Medications given at program. (PRN letters needed) LPA reviewed 4 resident and staff files including criminal record clearances. The annual fire permit is expired and needs renewal (Advisory given).

Fire drill was completed 12/2024. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete.