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25 | Licensing Program Analysts (LPAs) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Kimberly Yrigoyen and explained the reason for the visit.
Facility is licensed to served as an Adult Day Program with a capacity of 75 adults in the age range of 18 years and over, of which 60 adults may be ambulatory and 15 adults may be non-ambulatory. Facility has a lobby/locker/waiting room area, a conference room, 7 offices, an isolation room, a computer room, a media room, kitchen, gym, styling room, art room, staff break room, library, 4 restroom and 2 changing rooms.
LPA Flores conducted a tour with administrator and observed the following:
Facility is in good repair throughout. A fire sprinkler system was observed throughout. Kitchen area was observed clean, refrigerator is used to store clients' lunch. No chemicals were observed. Sharps are kept locked in a cabinet. Each restroom (4) is clean and in working condition, water temperature was tested in each restroom between 103.3 - 108.2 degrees F., which is not within the required 105-120 degrees F. First Aid kits were observed in three different areas with all the required items. Fire Extinguishers were last review on 4/29/24. Last fire drill was conducted on 1/11/24. Staff/Client ratio is 1:3.
LPA reviewed 5 staff and 5 client files. Individual Program Plan for clients #1,#2, and #4(C1-C4) are more than a year old. Program director does not have 30 hours of training. Staff #3(S3) is missing health screening. Infection control plan and Emergency Disaster plan were reviewed. Interviews were conducted with 4 staff and 4 clients.
Deficiencies noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with Program Director and a copy of this report, LIC 809D, and appeal rights were provided. |