The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This facility is an Adult Day Program (ADP) with an age range of 18 years and older. The facility fire clearance is approved for forty-five (45) clients, ten (10) of which may be non-ambulatory.

FOOD PREPARATION AREA/SNACKS: The facility is an Adult Day Program (ADP) and does not have a main kitchen for clients of the facility. The facility does have an area constituting the meal/snack area for clients during the day from 8:30am-2:30pm Monday-Friday. This area has a microwave, toaster oven, refrigerator, and various utensils/items for the preparation of snacks. The LPA inspected the food service area and observed that knives/sharp instruments are stored in locked drawers inaccessible to clients. All appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last 7 days in the event of an emergency. Additional perishable food items were maintained on a shelf. The hot water temperature was measured in the food service area at an appropriate temperature as per the regulation(s). There are no heating devices such as stoves in the facility. The food service area was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. Continued on 809-C

COMMON AREAS: At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. The facility maintains a main entrance lobby with sign in materials as well as COVID screening procedures. The facility has multiple Staff office rooms with desks, computers, storage cabinets, etc. The facility has two (2) large conference rooms that can hold all clients, sensory room, library, game room, woodworking room, media room, and garden room. There are no fireplaces on the premises. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintains a pool table, woodworking materials, gardening materials, puzzles, games, and multiple rooms for client activity. The facility maintained a comfortable temperature in all areas inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit in each of the buildings inspected. The fire extinguishers in all buildings inspected were fully charged and were last serviced in 2023. The LPA observed required postings throughout all common spaces. There are activity supplies and equipment, including reading, game, and media materials for the clients in all common areas inspected. All window screens were in good repair in all the areas comprising the facility. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all ramps are well-lit with sturdy hand railings/stair chair accessibility devices. This facility is one (1) story throughout and therefore there are no stairways for clients to utilize. As the facility has 11 clients and is a single story Adult Day Program (ADP), there is no signal system in place which was functional at the time of the inspection by the LPA.

OUTSIDE/LAUNDRY/MISCELLANEOUS (N/A): The facility is completely enclosed with a main entrance door and an emergency exit at the rear of the facility. There is a main entrance into the facility inside of a mini mall area on a public street. The facility has walls surrounding the interior of the facility. There are no bodies of water on the facility premises. There are no outdoor activity spaces for clients equipped with furniture for client use as this is an Adult Day Program (ADP) with facility transportation vehicles. This is an ADP facility with 11 current clients, therefore there is not a designated laundry room with the storage of cleaning products. There was emergency food and water in a storage room/area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to clients are kept in areas inaccessible to clients. Continued on 809-C

BEDROOMS (N/A): The facility does not have client bedrooms as this is an Adult Day Program (ADP) with a client schedule of Monday-Friday 8:00am-2:30pm. The entire interior of the facility is furnished with a smoke alarm/fire alarm system, emergency sprinklers, and appliances for the clients.

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are three (3) restrooms in the common areas of the facility that included soap, paper towels, required postings, and clean trashcans with closed lids. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per client in the facility. Nightlights are not necessary to be installed as the clients are only in the facility from 8:00am-2:30pm Monday-Friday.

INFECTION CONTROL: Upon entry to each building, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate isolation rooms if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The facility maintains a COVID-19 Infection Control Plan. There has not been an Infectious Disease Outbreak pertaining to COVID-19 at this facility. In the event of a positive COVID-19 outbreak, there is a designated room in the facility for isolation purposes with adequate amounts of PPE. Clients who test positive will be isolated according to the facility’s infection control plan.

RECORDS: The facility keeps confidential storage of personnel records and client records on-site at the facility. Staff member files were reviewed for, but not limited to personnel records, health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, Employee Rights, criminal record Statements, criminal record clearances, first aid/CPR certification that is not expired, and the appropriate training. All staff member personnel records had the appropriate documentation with no expiration of any training. Continued on 809-C

MEDICATIONS (N/A): The facility does not maintain a locked centralized storage area for client medications. There are no clients at the facility that take or must take any medications while at the Adult Day Program (ADP) facility from 8:30am-2:30pm Monday-Friday.

FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exiting plans with necessary telephone numbers. The facility keeps documentation of a Plan of Operation, Control of Property, The Job Description for Each Staff Position, Personnel Policy, In-Service Training for Staff, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Clients, Hazard Assessment, and Job Description for the Administrator. The facility is an Adult Day Program (ADP) and does not have on file a Dementia Care Plan document or Hospice Care Waiver.

No deficiencies cited. Exit interview conducted. A copy of the report was issued.