Facility Evaluation Report

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced required annual today. Upon arrival LPA met with the Administrator, Ernest Federer and explained the reason for the visit. Entrance interview conducted.

At approx 10:50 a.m. the LPA along with the Administrator toured the physical plant areas to ensure that there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The day program operates from 9:00 a.m. to 2:00 p.m. The day program is currently staffed appropriately with the necessary staff to client ratios. The day program consist of two (2) floors with seventeen (17) activity rooms.

The facility has one kitchenette for staff use. Refrigerator contains staff's lunch, snacks, and drinks. Clients are required to provide their own lunch. Activity rooms and office furniture were observed to be in good condition at the time of the visit. LPA observed hazardous/dangerous items secured in locked cabinets. Cleaning supplies were also observed locked and inaccessible at the time of the visit. The smoke detectors and carbon monoxide detector were tested and operational at the time of the visit. LPA observed the required postings throughout the facility. Fire extinguishers were observed to be fully charged and last serviced on 07/15/2024. Facility temperature is kept at a comfortable temperature. No bodies of water noted at the time of the visit. Activities are both designed for both as individuals and as a group. The LPA observed staff interacting with clients during time of visit. No obstructions or hazards were observed inside or out.

Records review began at approximately 11:30 a.m. Five (5) client records were reviewed for the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, Individual Program Plans (IPP), and current needs and services plan. All client records were observed to be in order at this time.