1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Senior Supervisor, James Perez, and explained the purpose for the visit. Program Director, Adela Zambrano arrived shortly after to assist with the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Supervisor, observed the facility food supplies, reviewed, (6) client files, (6) staff files, and conducted interviews with (5) staff, and attempted interviews with (6) clients. The facility is a two-story building, operating as an Adult Day Program. It is licensed to serve (60) Developmentally Disabled adults, ages 18-59. There is a fire clearance approved for (5) non-ambulatory residents. Hours of operation M-F 8am to 4pm. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file.
LPA observed activity rooms to be clean and free of hazards. There were small rooms equipped with beds for client use. Beds had the required linens, were clean, and in good repair. Bathrooms were observed to have the required grab bars and were free from odors. The hot water was tested and measured between 120*F, which is in compliance. Clients provide their own lunch and snacks. Sufficient staff were observed to provide care to the clients in care and were present at all times. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to clients in care. The last emergency disaster drill was conducted on 4/18/24. Smoke/Carbon monoxide detectors were observed in every room and operational. No bodies of water were observed on the premises. (6) Client files and (6) staff files were reviewed and observed to be complete with all required documentation. Staff files were observed to have proof of current CPR and CPI certification.
No deficiencies were observed or cited, during today's visit.
An exit interview was conducted and a copy of this report was provided. |