Facility Evaluation Report

On 3/12/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Licensee (L1) Susan Baal, LPA was granted entry. 4 residents were present during inspection.

LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Samples of resident’s medications were checked and observed locked in kitchen cabinet. Clients’ MARS was reviewed. Fire extinguisher reviewed with a service date of: 3/15/25. Fire drill completed on 12/20/24. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in closet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 106.7 to 108.5 degrees in 2 bathrooms.

Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 0 degrees F and refrigerator temperature maintained at 32 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. All clients’ files and staff’s files reviewed to have all of the required documents. First Aide kit observed to have all of the required items.