Facility Evaluation Report

***AMENDED...This is an amended version of the original report created on September 14, 2023. LPAs conducted annual at the facility's wrong location. LPAs came to this facility to inspect the physical plant. LPAs toured the facility and grounds. Program shares building with other organizations. Building management provides maintenance including water. Most recent fire/disaster drill was conducted June 2023. Toxins were locked under kitchen sink and were inaccessible to participants. ***Amended on 9/19/23.

Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced to conduct an Annual Required inspection and met with Paula Finley (Chief of Services). Currently the facility is operating Monday-Friday between 8:30am to 2:30pm. Facility provides daily outings into the community as well as site-based activities.

At 9:00 am LPAs/staff conducted inspection and toured the facility and grounds. Required postings were observed. Bathrooms used by participants were sanitary and in good repair. Smoke; fire extinguisher are tested annually, carbon monoxide inspected regularly by Fire Department. The facility's fire extinguishers were last serviced July 20, 2023. Facility was a comfortable temperature and passageways were free from obstructions. Water in bathrooms measured within allowable range. Facility has personal lockers for participants to store their personal items. Participants bring lunches/snacks and there is a refrigerator available for them. Facility doesn't handle cash resources. Facility van was inspected and contained a first aid kit and fire extinguisher was charged and serviced. First aid kit was fully stocked. Medication and medication records were reviewed. At 10:00am LPAs initiated file review of five participants and five staff. Staff have required First Aid and CPR training. Participant's files have current medical assessment and appraisals/needs and services plans. Facility will provide updated copies of the following documents by 9/22/23: Designation of Responsibility (LIC308) and Personnel Report (LIC500).

Exit interview was conducted with Chief of Services and a copy of this report was given.

No deficiencies were cited during today's inspection.