Facility Evaluation Report

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection visit of the facility. LPA was welcomed by Licensee/Administrator, Mariah L. Uden. There are 5 clients at facility.

At approximately 9:30 AM, LPA toured the building and grounds which was found to be clean and in good repair, LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secured in locked laundry room cabinets, not accessible to clients. Medication is centrally stored and secured in the office. There is a sufficient supply of hygiene products and linens on hand for client use. Water temperature measured 113.9 degrees F, within regulation between 105 and 120 degrees F at faucets accessible to clients. 2 Fire extinguishers viewed were charged and last inspected 02/01/2024. Smoke detectors and Carbon Monoxide detectors were tested and found to be in working order. Facility has pull station for fire alarm. Disaster Drills are conducted quarterly with the last being a fire drill conducted on 02/01/2024.

LPA reviewed 5 out of 5 Client records and 4 of 4 Staff records. At approximately 10:20AM, LPA reviewed 5 of 5 Client records. 5 of 5 client files have current Appraisals and contain completed admission agreements.

At approximately 11:45AM, LPA reviewed 4 of 4 Staff records, which contained the required documentation; although staff (S1) did not have TB test results (see LIC.809-D) First aid and CPR certification were current in staff files reviewed.

The Medications of 2 out of 2 clients were found to be given according to physicians’ directions on 3/7/2024 at approximately 1:00 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. Facility does not handle P&I monies. Administrator's Certificate for Maria Uden expired on 07/30/2023 and new certificate is pending.