Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez arrived at the Adult Day Program (ADP) unannounced to conduct a required annual visit at 11:15 a.m. The LPA met with Program Director Iokany Parra and explained the reason for the visit. The program currently operates from 8:00 a.m. to 2:00 p.m. The day program was staffed with 1:1 staff to consumer ratios and with one group of 1:3 staff to consumer ratio.

Record Review : At 11:30 a.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, and last fire drill (conducted on 05/31/2023. The LPA obtained Client Roster, Staff Roster, and Staff schedule. The LPA reviewed five (5) of eight-teen (18) Client Files. One out of five client files (C1) did not have an admissions agreement, and one out five clients did not have a medical assessment with Tuberculosis test results. The LPA reviewed five (5) out of thirteen (13) staff files. All staff documents reviewed appeared complete and current.

Infection Control: Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility's procedures as it pertains to infection control are adequate.

Interview: During today's visit, the LPA interviewed three (3) staff and three (3) consumers. No immediate concerns voiced at this time.

Medication Audit: A medication audit for two (2) clients was initiated at 3:15 p.m. and the following was observed. Medications are centrally stored and locked in a locked cabinet in the Program Directors office; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. The LPA observed both clients have PRN medications, and the Day Program does not have a PRN Authorization Letter on file for one out two consumers, to indicate whether the consumer is able to make their own decision or if the doctor needs to be contacted prior to assisting the residents with the PRN medications. Report will continue on LIC809-C.