Facility Evaluation Report

On January 9, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Program Director, Maria Villacorta and Program Supervisor, Evelyn Raz and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water observed. There are 6 activity/classroom areas. Rooms were observed to be clean, clear from tripping hazards, and spacious. Clients were observed to be participating in group activities with a sufficient amount of staff supervising. LPA observed 4 single bathrooms to be clean and odor-free. 3 office rooms and one conference room was observed. Changing room was observed to be clean and odor-free.

Kitchen was observed. LPA observed kitchen door locked unless staff is present. According to the Program Director, clients bring their lunches to the day program. Clients are able to store their lunches in the refrigerator. LPA observed chemical bottle on the kitchen floor not stored away and accessible to clients. Kitchen was observed to be clean and free from pests and flies. Sharps were observed to be stored appropriately and inaccessible to clients. Staff break room was observed to be locked. Room was overall clean, however LPA observed another chemical bottle on the floor not stored away. Medication was observed to be locked and inaccessible.

LPA toured the beauty room and observed a bottle of acetone on the table, open and accessible to clients in care. LPA toured the garage and observed indoor garage to be cluttered with boxes, trash bags and furniture. There was no walking room for LPA.

LPA checked all fire extinguishers which were inspected on 05/2023. Two Carbon monoxide detectors were observed to not be in working condition. First aid kit was observed to be present. There are a total of 6 facility vans that get serviced every 3 months. Last service date was December 11, 2023. LPA reviewed facilities emergency disaster plan. The last disaster drill was conducted on July 10, 2023. (continue to 809C)