Facility Evaluation Report

On 10/08/2025 at 12:00PM, Licensing Program Analyst (LPAs) Andrew Christy arrived unannounced to conduct a Proof Of Correction (POC) visit. LPA met with administrator Mary Malekamu and explained the purpose of the visit. The facility currently houses four (4) residents.

The following deficiencies cited during the annual visit on 09/22/2025 were cleared during this visit:

87307(d)(6) - The fire exit through the backyard was cleared on the original POC date with photo proof sent to LPA. During today's visit, the pathway was still clear.

87303(a) - The fridge's busted freezer drawer now opens properly. Administrator has a contractor coming out to fix the windows and screens with a date of 6-8 weeks. Administrator will send a picture of contractor doing work within a week of that date.

87411(a) - There was additional staff during POC visit that were able to effectively communicate with residents and LPA.

1569.618(c)(3) - All staff have gotten their CPR cards and administrator sent email proof.

1569.695(b) - The emergency drill was ran during the last week of September with all employees having signed the form. Administrator verbalized understanding that this needs to be done every three months.

87412(a) - Staff have the necessary forms that were discussed during the initial Annual Visit besides the LIC503. Staff have their health screenings scheduled and administrator will submit the forms after each one is done.

87506(b) - Residents have the necessary forms that were discussed during the initial Annual Visit.