Facility Evaluation Report

On 5/5/2023 at approximately 9:50am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a required 1 year annual visit. LPAs Jensen and Fain met with Senior Program Manager Shirley Ridoloso and explained the purpose of today's visit.

LPAs Jensen and Fain toured the physical plant including the activity rooms, computer lab, changing rooms, kitchen, and bathrooms. There are 26 clients attending program in person and another 34 clients engaging in day program remotely. All required signs are posted in prominent areas including but not limited to personal rights, employee rights, Ombudsman, COVID mitigation, Provider Information Notices and facility Sketch. The facility was observed to be sanitary and free of odor. The thermostats were set at a range of 68-69 degrees for the comfort of the clients. The facility smoke detectors and carbon monoxide detectors were tested and determined to be in good working order. The fire extinguishers were last serviced in March of 2023. There are two first aid kits that were observed to be complete with scissors, tweezers, thermometer, various wound dressings and manual. The water temperature was measured in bathroom at 110 degrees Fahrenheit which falls within the required range of 105-120 degrees. Grab bars were observed in all bathrooms. Garbage cans with tight fitting lids are being utilized throughout the facility. There is an emergency supply of water on site. The facility maintains emergency lighting. The facility conducts regular disaster drills. There was a variety of activities available for clients including arts and crafts and activities for mobility development. During the course of the visit the clients were engaged in games and singing activities.

LPA Jensen reviewed 3 of 13 staff files and 5 of 26 client files. All files were found to be complete and in compliance.

The facility was determined to be in substantial compliance. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was provided.