Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Required 1 Year inspection at facility today. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Lydia Sattiewhite at 11:41AM. Entrance Interview conducted.

The LPA, along with Administrator, toured the physical plant area at 11:45AM to ensure there are no health and safety hazards and the day program is in compliance with Title 22 Regulations. The following was observed:

The facility was found to be in compliance with the staff to client ratio. Administrator informed LPA that there is a limited number of clients participating in in-person day program services at this time and the remainder are utilizing the program virtually. The LPA observed the three activity rooms, of which only one was in use during today's visit. Facility records, first aid supplies, and medications are locked and inaccessible. The clients bring their own lunch to program. The facility had a supply of snacks and drinks for clients and emergency food and water. The fire extinguishers observed were fully charged and last serviced on 06/29/2021. The smoke alarms and carbon monoxide detector were tested at 12:00PM and were operational. The clients bathrooms were observed to be clean and sanitary with hygiene supplies.

During today’s visit, the LPA spoke with Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and hand sanitization. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate an isolation area for any symptomatic individuals awaiting pick up from the program. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.