Facility Evaluation Report

On 5/23/2026 at approximately 01:20 PM, Licensing Program Analyst (LPA), Angelica Segovia conducted an annual visit to the facility. LPA was greeted by the facility’s representative, David Slattery who was designated to sign today’s report per the Administrator, Jennifer Fogelstrom.

LPA conducted a physical plant tour at approximately 1:30 PM and the following was noted:

The facility is a single-story building with four (4) bedrooms and two (2) bathrooms. The facility is currently non-operational and occupying zero (0) residents. There is no designated staff room. The facility has an approved fire clearance for six (6) non-ambulatory residents of which one (1) may be bedridden. Hospice waiver approved for six (6).

Common areas: The living room and dining room were observed. The rooms were observed to be properly furnished and in good repair. Required postings such as Long-Term Care Ombudsman, Emergency Disaster Plan, and Personal Rights will be posted before residents’ arrivals. LPA observed the fireplace to be covered.

Kitchen: Sufficient supplies of seven (7) day nonperishable food and two (2) day perishable foods will be purchased prior to residents’ arrival. Kitchen appliances were observed to be in proper condition. (continued LIC 809-C)