Facility Evaluation Report

On 9/14/23 at 10:40 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced Annual/Required visit. LPA met with Susana “Susie” Mix, Administrator, and explained the purpose of the visit.

LPA toured the facility with the Staff #1 (S1). The program is community based. Upon entry to the facility, there were three clients present, and then two clients left the facility during the visit. Administrator states the day program is open Monday through Friday, 9:00 am to 3:00 pm. Hot water temperature measured between 113.6 F and 114.6 F degrees. All toilets and hand washing facilities are maintained in a safe, sanitary, operating condition. The program site is clean, safe, sanitary and in good repair for the safety and well-being of clients, employees, and visitors. Facility is maintained in conformity with state fire marshal regulations. Smoke and carbon monoxide detectors were tested and functioning. Each client is accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs. Snacks are provided and clients bring their own lunches. Food is stored and prepared in a safe and healthful manner. Disinfectants, cleaning solutions and poisons are inaccessible to individuals. Facility has adequate emergency and first aid supplies. Fire extinguishers (4) were located in the main room, hall near activity room, storage/kitchen, and dining room. Extinguishers were fully charged and last inspected on 6/07/23. Facility temperature is 75 F degrees. Outdoor walkways are free from obstruction. LPA observed staff sufficient for client ratio. Emergency disaster drills were conducted quarterly in 2023. Administrator states the facility was in operation in 2022 but was not serving clients at the facility. LPA conducted a file review of 5 clients. Client files reviewed had physician reports, admission agreements and current needs and services plans. All files were in compliance. Administrator states staff do not assist clients with medications, and medications are not stored in the facility. LPA conducted a file review of 5 staff for criminal record clearances and associations, Health screening with TB results and current First Aid/CPR. Staff records were complete. The facility’s Emergency Disaster Plan (LIC 610D) is complete and posted in the facility.

Exit interview conducted, technical violations issued, and the report given.