Facility Evaluation Report

Licensing Program Analyst (LPA), Alviso, conducted a required- 1 year visit, on 7/31/25 at approximately 10:00am, and met with Dungarvin Area Director, Jesse Hanson, and Program Director, Felicia Kualapai.

There are thirty-five (35) clients in attendance today, and twenty-one (21) of the clients are in the community with supervising staff. There are twenty (20) staff working at the day program today, and twelve (12) of the staff are in the community with the clients.

Day program has a fire clearance for forty-five(45)) capacity, of which twenty (20) may be non-ambulatory. The facility has a required infection control plan. The facility has a required emergency disaster plan. There is a first aid kit with emergency supplies. Fire drills are held monthly, last fire/emergency drill was held on 7/17/25.

Facility has five (5) transportation vehicles/vans that have current insurance coverage, and current maintenance records, per file reviews.

The LPA reviewed six (6) client files. Files were complete. The LPA reviewed six (6) staff files. Per record review, staff had criminal record clearance as required; All staff had first aid and CPR certification. Staff had manual restraint training, per program plan and regulation requirements, per review of training records.

LPA toured the facility with Area Director Jesse, and Program Director Felicia. Hot water was measured at 111.7 degrees Fahrenheit, which is within regulation. All exits were free and clear of obstruction. All walkways and outside pathways were free and clear of obstruction. The courtyard area in back of the facility was orderly and had seating areas for client use.