Facility Evaluation Report

On 11/6/2025 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an annual inspection. LPA was greeted by Merilyn Bergstrom and allowed entrance into the facility. LPA conducted the tour with Amy Rawlins.

LPA observed the facility to clean, odor free, and clutter free. All exits are free from obstruction. The facility is licensed for 6 residents, and currently has a census of 5. The facility has 5 bedrooms and 3 bathrooms. Each resident has their own room. LPA observed resident rooms to be properly furnished with sufficient lighting.

LPA observed chemicals, knives, and medications to be locked and inaccessible to residents in care. LPA reviewed a sample of staff files and resident files which are current and complete. LPA observed a sample of resident's medications which were observed to have no errors and are properly labeled on a centrally stored log. PRN paperwork is on file for residents with PRN medications.

LPA observed water temperature in kitchen which read at 111.8 degrees Fahrenheit and in the hallway bathroom which read at 107.8 degree Fahrenheit. Smoke detector and carbon monoxide detector were tested and are in working order. LPA observed fire extinguisher last serviced August 25, 2025.

LPA observed no deficiencies and no citations were issued during today's visit.

Exit interview was conducted and a copy of this report LIC809 was provided to Amy Rawlins.