Facility Evaluation Report

On 6/10/23 at 10:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Assistant Program Manager Michelle Monahan and explained the purpose of today's visit. The facility currently has a census of 16. There are 4 staff members and the Administrator who is present 2 days a week.

LPA Jensen toured the grounds. There are no bodies of water on the property. There are shaded areas available for outdoor activities. The facility maintains a garden with raised beds and bird feeders for use by clients. The window screens were observed to be in good repair. All paths were free of obstruction.

LPA Jensen toured the physical plant interior. The Day Program consists of a variety of activity rooms including a computer lab and music room as well as offices, bathrooms and a kitchen. The lighting and furnishings were observed to be adequate and in good repair. The facility was observed to be sanitary and free of odor. The thermostat was set to 70 degrees during the course of this inspection. The water temperature in the bathroom was tested and measured to be within the required range. Knives and medications were observed to be locked and inaccessible to residents in care. LPA Jensen observed a bottle of bleach and 3 bottles of isopropyl alcohol in a cabinet in the art room under the sink. The items were immediately removed and locked, technical assistance is being provided on storage of toxins. LPA Jensen observed 3 of 4 fire extinguishers were last serviced November 21, 2022. During the course of this visit, the Assistant Program Manager scheduled a service with the Fire Marshal for tomorrow, 6/11/24. LPA Jensen tested 2 smoke detectors and 2 of 2 were not functioning. 1 of 2 non-functioning smoke detectors were removed from the ceiling and stated on the back portion that attaches to the ceiling that it was manufactured in 2009 and should be replaced within 10 years. The first aid kit was determined to be complete. The facility conducts and logs emergency evacuation drills. The most recent evacuation drill was conducted in February of 2024 and is in compliance.