Facility Evaluation Report

At approximately 10:15 AM Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required inspection of facility and was greeted by staff. Administrator, John Ahrens arrived at a later time. Facility’s fire clearance granted for 15 Ambulatory clients. Facility census is 15 although 1 client is currently at family visit.

At approximately 10:20 AM LPA and staff Jenny toured facility, 20 minutes later administrator, John Ahrens arrived to continue tour of facility; facility was found to be at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. In addition, Bathroom #2 had 2 broken toilet seats (see pictures) and clogged sink with duct tape over basin, although still being used by clients (see LIC809D) Administrator informed getting plumber to service. LPA and Administrator inspected over half of client bedrooms finding many with garbage on the floor, smelling of dirty laundry (see pics) but once advised by Administrator began cleaning. Fire Extinguisher was found to be last charged on 02/07/2025 at the time of the visit. Carbon monoxide detector was not found during the visit (see LIC9102 Advisory Notes). Facility has hard wired smoke detectors and sprinklers with last inspection dated 3/25/2025. Hot water temperature measured between 128.1 degrees F and 136.2 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 3 client’s bathroom while touring facility at 10:30 AM (see LIC809D). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the facility in the hallway; although unlocked at 10:25AM and 11:30AM as observed by LPA and Administrator (see LIC809D). Dangerous items were not stored inaccessible to clients finding unlocked meds and scissors in the office room; and when LPA entered facility there were 2 clients sweeping and cleaning in dining room and kitchen with no staff visible and kitchen knife drawer was unlocked along with cleaning supplies under kitchen sink left unlocked (see pictures & LIC809D).