Facility Evaluation Report

On 12/31/2024 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by Caregiver Rachel Langan. LPA stated the reason for their visit. The Facility Representative Glen Hulse arrived shortly after to assist with today’s visit.

LPA asked for census, staff, and resident files. LPA conducted a physical plant tour at approximately 10:30 AM and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with four (4) bedrooms and two and a half (2.5) bathrooms currently occupying two (2) residents. No designated staff room.

Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Required postings such as See/Say Something, Long-Term Ombudsman, and Resident’s Rights were located alongside entrance.

Common areas: Living room and dining room observed to be neat, clean, and organized. Common areas observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 76°F. Fire extinguisher located near the sliding door leading towards the backyard and dated 12/31/24. Electric fireplace observed to be covered and located in the living room inaccessible to residents. Working telephone located in living room.

The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Knives and sharps observed to be locked in a locked box located on top of kitchen counter and inaccessible to residents. (continued on LIC 809-C)