Facility Evaluation Report

on 10/10/25 at 11:30am Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a case management in association with a previous complaint. LPA met with cheryl Boehme and Nataliya Regan, and explained the purpose of the visit.

The Physical inspection included but was not limited to, kitchen, exteriors, evacuation routes, common areas, storage areas, resident bedrooms, and resident bathrooms. facility is clean, traffic areas are unobstructed and well lit. The bathrooms have functional hardware, the water temperature is delivered between 105-120, metered at 3 locations at varying distances from the heaters. Resident bedrooms have all required furniture and furnishings. Exteriors have no torn/bent/missing screens, its clean and there is space for activities, some exterior gates have locks for various periods of time, LPA gave guidance that the designated fire exits are to remain unlocked. LPA observed the storing of medication outside of its orginal container in the med room, citation was issued. Evacuation drill log was checked, it happens at least once a quarter. Kitchen repairs are almost complete, about 50% of the floor still has to be replaced, a plain exists to provided uninterrupted basic services during this repair.

3 residents interviewed, 3 staff interviewed. no staff files, no client files were reviewed. procedures for prn documentation, and med refusal documentation are improved in their description to the LPA but not yet implemented. LPA gave the guidence that those procedures as described should be added as an ammendum to the program design and submitted to the department for review.

One citation was issued in connection with the visit. a copy of the appeal rights was given to the administrator. a exit interview was conducted, a copy of the report was read and given to the administrator.