Facility Evaluation Report

On 10/09/2025 at approximately 9:25AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct a Required 1 Year visit and met with Administrator, Briana Terrell. Facility is an Adult Day Program for Adults with Disabilities. Facility has an approved fire clearance and capacity for 90 Clients, of which 9 Clients can be non-ambulatory. Upon arrival, LPA was informed that there were 66 clients attending Day Program and 26 staff members on-site. Facility is a two-story building with 5 classrooms, 4 bathrooms, 5 staff offices, library room and common areas. Facility provides mostly in-person services, Monday through Friday from 9:00 AM - 3:00 PM. Participants were participating in a variety of activities at the time of visit.

At approximately 10:15AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 10:45AM, LPA and Program Director toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. LPA observed activity supplies for resident use. Chemicals and other items which could pose a risk to clients in care stored in locked metal cabinets and closets. Soap & paper towels were available in facility bathrooms. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Water temperature measured 108.6 degrees F and 113.2 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers were charged and were last serviced 6/2025.

Facility is hardwired with a fire sprinkler system which was failed in the last annual inspection and report was indicating new parts need to be ordered (See LIC809-D Page). Administrator agrees to submit new inspection results once the issue fixed. There was enough lighting in all common areas and hallways.