Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon arrived at 10:30 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Christina Hutchison and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan, and Emergency Disaster Plan to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). 1 out of 5 trash cans and waste baskets have tight fitting covers. Facility needs to be cleaned and disinfected. Restrooms need to be cleaned and disinfected.

Physical Plant & Environmental Safety: The facility is a day program with 2 restrooms currently serving 21 clients and employs 13 staff. The facility needs to be cleaned and sanitized. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors both tested and working. The lighting and lamps are not sufficient due to many of the bulbs are no longer working. The facility does not have a kitchen. The facility refrigerator is clean and operating at required temperature. Toilet and hand washing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to clients in care locked in cabinet in the activity area. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service. Water temperature was checked in restroom #1 at 99.3 and restroom number 2 at 102.9 which is below the required regulation. Staff Manager adjusted the water heater and will monitor with a 7 day log for required temperature.