Facility Evaluation Report

On 12/18/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility regarding an annual inspection. LPA Campbell met with Executive Director Rita Redondo and spoke to Jessica Hogan Program Director and explained the purpose of visit. Upon entry, LPA Campbell observed clients entering the facility and going to a meeting room to listen to music and coffee break.

The facility is a one story building with 10 classrooms, a kitchen, medication dispensery room and reception room. There are four bathrooms as well. Classrooms surround a large room where clients can gather. The facility is licensed to have 94 ambulatory clients and 6 non-ambulatory clients and is open from 9 am to 3 pm.

The first aid kits were reviewed and found complete with tweezers, scissors and a thermometer. The Medication Administrator Record (MAR) was observed to record client medications, included photos of the clients and the date and initial of the person who dispensed the medication. Clients with PRN medications were included in the MAR as well.

LPA Campbell reviewed the fire drill log for the facility. Records show that there have been three fire drills in 2024. The facility recorded the date, time and location. After consulting with the Executive Director, LPA Campbell provided further resources for future drills.

Of the three staff files reviewed during the visit, all were found to have been fingerprint cleared. LPA Campbell suggested that employee start dates be included by the employees names on the file tab and that the employees titles be listed on job applications when hired. Of the five clients whose files were reviewed, five of the files were found to be complete. LPA Campbell has requested that the facility highlight the admission agreements to make them easier to find.