Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an annual required inspection based on infection control and met with Administrator, Jim Bernard. The program will be open Monday through Friday from 9:00am to 2:30pm. LPA conducted risk assessment with Administrator at the facility. Upon arrival LPA had their temperature checked and it was documented in an iPad.

LPA/Administrator toured the premises inside and outside, facility consists of a kitchen, 2 bathrooms, computer room, library, activity room in the main area, art room, an outdoor patio with seating and a staff office. The program is not open for in-person classes, there are 30 participants that are receiving alternative services through online activities and staff drop off activity packages including arts and crafts supplies for participants in average once a week. LPA/Administrator reviewed PIN 21-36 ASC, PIN 21-33 ADP and PIN-21-44 ASC. Facility has a centralized sign-in electronic sheet located at loading area where facility documents staff, visitors and eventually participants daily screening. 10 out 11 staff are completely vaccinated; staff who is not vaccinated is still required a weekly surveillance testing. Facility will provide transportation services and they will ensure to screen participants before they can get on the vans as well as facility will screen participants at facility entrance. Administrator agrees to submit a re-entry plan including transportation services to CCL for review prior to participants come back to the day program. Staff was observed wearing a mask while in the facility. All staff have received required training on infection control, but not all the staff have been N95 fit tested yet. Regular maintenance plan includes sanitize every hour or as needed. Facility has automated dispensers to dispense hand sanitizer. Facility has posters that are posted through the facility including bathrooms encouraging participants to wear a mask and maintain social distancing. Facility has sufficient personal protective equipment for staff and participants including face shields, gloves, hand sanitizer and masks. Facility has submitted their Mitigation Plan and it was approved as of 3/25/21. Administrator agreed to notify CCL before re-opening for in-person classes. Administrator agreed to submit the following documents to CCL by 12/24/21: Lease agreement.

No deficiencies cited during today's visit.