HomeMy WebLinkAboutAdult Life Program Inc 480000 07 11 17.pdfName Change
Verification of Closure
Status Change
Inspection
Re-inspection
Visit
STORAGE: (.3317, .3320)
*30. Medications and hazardous products properly stored
and locked ........................................................................
31. Facilities provided for proper storage, kept clean .............
BEDS, LINENS, FURNITURE AND EQUIPMENT: (.3321, .3322)
32. Beds, chairs, cots, or mats clean and in good repair, stored
properly ............................................................................
33. Mattress covers, individual linen provided .......................
34. Linen clean, in good repair; properly handled and stored ....
35. Other furniture and equipment easily cleanable, good repair
clean ...................................................................................
PERSONNEL: (.3323)
36. Approved hygienic practices, clean clothes, hair restraints
where required ...................................................................
37. Tobacco not used in food prep areas or areas occupied by
non-smokers ......................................................................
*38. Persons with communicable disease or a
communicable condition excluded from situations
in which transmission can reasonable be expected to
occur, in accordance with 15A NCAC 19A.0200 ..........
*39. Wounds or lesions properly bandaged..........................
FLOORS, WALLS & CEILINGS: (.3324, .3325)
40. Easily cleanable, durable, good repair, clean ......................
LIGHTING AND THERMAL ENVIRONMENT: (.3326)
41. Maintained as required .....................................................
42. Equipment clean and in good repair ..................................
COMMUNICABLE DISEASE CONTROL: (.3327)
43. Designated area for sick participants ................................
44. Treatment room provided for day health facilities ............
HANDWASHING: (.3308, .3319, .3328)
45. Proper handwashing ..........................................................
WASTEWATER: (.3329)
*46. Wastewater disposed of by approved methods .............
SOLID WASTES: (.3330)
47. Solid waste properly handled ............................................
48. Can cleaning facilities adequate and containers kept clean..
ANIMAL & VERMIN CONTROL: PREMISES;
OUTDOOR ACTIVITY AREA: (.3331, .3332)
*49. Approved pesticides, properly used ...............................
50. Effective control of rodents, insects, and other vermin .......
51. No animals in food prep areas and no unrestrained animals
except as noted ..................................................................
52. Premises clean, drained, and free of hazards, vermin
harborages and breeding areas ............................................
SWIMMING & WADING POOLS: (.3833)
*53. Designed, constructed, operated and maintained in accordance
with 15A NCAC 18A .2500 .............................................
FOOD: (.3304, .3305, .3306, .3307, .3308, .3310)
*1. From approved sources, free from spoilage and
adulteration .....................................................................
2. Potentially hazardous food temperatures .........................
3. Properly prepared, handled, packaged, and identified ......
4. Not re-served .....................................................................
5. Protected at all times according to these rules ...................
6. Refrigerators with thermometers, product thermometers
provided ...........................................................................
FOOD SERVICE EQUIPMENT AND UTENSILS:
(.3304, .3306, .3307, .3309, .3310, .3311, .3312, .3313, .3314, .3316)
*7. Meets specifications for refrigeration, sinks, and dishwashing
equipment according to type of service ........................
8. Meets requirements for handwash lavatories ....................
9. Meets specifications for other equipment and utensils,
approved material and construction, in good repair ..........
*10. Food contact surfaces, including multi-use utensils,
properly washed, rinsed and sanitized .........................
*11. Single-service articles not reused ................................
12. Single-use articles not reused .............................................
13. Non-food contact surfaces clean .......................................
14. Equipment and utensils, including single-service articles,
protected from contamination ...........................................
15. Approved testing equipment for sanitizers, sanitizing
solution provided ..............................................................
WATER SUPPLY: DRINKING WATER FACILITIES: (.3315, .3316)
*16. Supply meets 15A NCAC 18A .1700 or 15A NCAC
18C ....................................................................................
*17. Hot water supplied and maintained in accordance with
this section. ......................................................................
18. No cross connections, backflow prevention device
provided ............................................................................
19. Drinking fountains or drinking utensils of approved type,
regulated, clean ..................................................................
TOILET AND LAVATORY FACILITIES: (.3310, .3317, .3318, .3319)
20. Toilets and lavatories provided, properly located ............
21. Fixtures properly sized, cleaned, sanitized, cleaning and
and sanitizing solutions provided ......................................
22. Potty chairs, bedpans, urinals properly located, cleaned
and sanitized ......................................................................
23. Soap, disposable towels or approved hand-drying device;
lavatories free of storage ....................................................
24. Approved clothing changing facilities ...............................
25. Clothing change and bathing surfaces cleaned and sanitized
after each use; cleaning and sanitizing solutions provided
and labeled.. .......................................................................
26. Approved clothing changing methods by caregivers .........
27. Test kits provided; sanitizer labeled .................................
28. Clothing changing surfaces clean and free of storage .........
29. Handwashing signs posted ................................................
Signed _______________________________________________AGENT
Division of Environmental Health
5
4
N.C. Department of Environment and Natural Resources
Division of Environmental Health
4
Old Facility ID
4
Inspection of Adult
Day Service Facility
4
Classification:
Health Department
Current Facility IDDate of Insp/Chg:
Score:
Status Code:
Name of Facility Operator:
Address (City, Zip Code):
Purpose: General Statute 130A-235 requires the Commission for Health Services to adopt standards governing the sanitation of child day care facilities. G.S. 130A-235 requires the facility to submit evidence to the Division of
Facility Services or Division of Aging that it conforms to the standards. This form is to provide such evidence. Preparation: Local environmental health specialists shall complete the form every time an inspection is conducted and
prepare an original and two copies to be submitted: 1. Original for Division of Child Development, N.C. Department of Health and Human Services. 2. Facility operator. 3. Local health department. Classification: Superior - 0-15
demerits, no 6-point demerit Approved - 16-30 demerits, no 6-point demerit Provisional - 31-45, or 6-point demerit Disapproved - 46 or more demerits, or failure to improve Provisional classification Disposition: Please refer to
Records Retention and Disposition Schedule 8.B.6., for County/District Health Departments which is published by the North Carolina Division of Archives & History. Additional forms may be ordered from: Division of Environmental
Health, 1632 Mail Service Center, Raleigh, NC 27699-1632, (Courier 52-01-00)
EHS 4054 (7/05) Environmental Health Services Section (Review 7/08)
*Indicates critical item (6-point demerit).
Demerits Demerits
Comment Sheet Attached
Water sample taken today?1
2
V
EHS I.D.#
6
544
4
3
65
4
6
6
3
554
4
3
5
6
6
62
4
4
3
6
6
4
4
45
32
2
4
42
55
5
6
22
6
4
4
4
6
Yes No
Yes No
//
Superior Approved Provisional Disapproved
Wastewater:Municipal/Community On-Site System
Municipal/Community On-Site SupplyWater Supply:Maximum
Capacity
18
2018480000
8
0 7 1 1 2 0 1 7
A
2 9
ROMIE RECTORADULT LIFE PROGRAMS INC
211 2ND AV PL NE CONOVER 28613
2031 - Levin, Paige
8
N.C. Department of Environment and Natural Resourses
Division of Environmental Health
COMMENT ADDENDUM
Time In:
Time Out:
Total Time:
City:
Street:
ID:
Name:am
pm
am
pm
:
:
ADULT LIFE PROGRAMS INC
2018480000
211 2ND AV PL NE
CONOVER
1 0 3 2
1 1 4 5
1 hr 13 minutes
22
40
Need to clean toilet in men's restroom.
Carpets badly stained. Need to repaint/ repair wall in men's restroom.
N.C. Department of Environment and Natural Resourses
Division of Environmental Health
COMMENT ADDENDUM City:
Street:
ID:
Name:ADULT LIFE PROGRAMS INC
2018480000
211 2ND AV PL NE
CONOVER
N.C. Department of Environment and Natural Resourses
Division of Environmental Health
COMMENT ADDENDUM City:
Street:
ID:
Name:ADULT LIFE PROGRAMS INC
2018480000
211 2ND AV PL NE
CONOVER
N.C. Department of Environment and Natural Resourses
Division of Environmental Health
COMMENT ADDENDUM City:
Street:
ID:
Name:
General Comments:
ADULT LIFE PROGRAMS INC
2018480000
211 2ND AV PL NE
CONOVER