Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 9/24/2021 at 10:25am. LPA met with Designee Jana Vann and stated the purpose of today’s visit and was allowed entry into the facility and was accompanied by Jana throughout the inspection tour of the facility that is licensed to serve a total capacity of 70 clients. Today's census is 62 enrolled in remote alternative services and 1 client coming on site. LPA observed six of six staff present associated with criminal record clearance in Licensing Information System. Program Director arrived on site during the inspection.

The facility is a Day Program that has not been operating in person services since March 2020 but have been providing remote services to clients via Zoom, other video programs and sending packets. The day program has with a large central open area for services, two restrooms, staff office, isolation room, and kitchen with staff break room set up to meet clients needs and abilities. LPA observed tables and chairs to serve the capacity of the day program and promote social distancing. LPA observed staff conducting zoom with clients and 1 in person service.

The day program is looking at new reopening requirements and following State guidelines prior to increasing on site clients for in person services. The physical plant was toured inside and outside to ensure the safety of the clients. The kitchen faucet was observed broken not regulating water temperature. The temperature inside the facility was measured at 75*F which is within the required range of 68*F and 85*F. The hot water was measured at 108*F in the restroom which is within regulatory range of 105*F and 120*F. LPA observed first aid kits was found in compliance containing at least the following: a current approved edition of a first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed fire extinguisher last inspected on 6/4/2021, smoke and carbon monoxide detectors, central heating and air in the facility. Last fire drill was conducted on 9/3/2021.