Facility Evaluation Report

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with House Manager Will Praiphetsak. At approximately 8:45AM, LPA toured the building and grounds which was found to be clean and orderly. LPA observed the back deck ramp has a potential trip hazard at the base, where the boards are raised and the concrete is crumbling. The emergency exit gate was observed to be tied closed with string, preventing it from being opened. This is a repeat violation within a 12 month period. An immediate civil penalty is being issued in the amount of $1000. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors in the living room, hallway and one residents room had their batteries disconnected. This is an immediate Safety risk to residents in care. An immediate civil penalty is being issued in the amount of $500. Staff replaced batteries during visit and alarms were functional. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Most medication is centrally stored and secure, however, a bottle of vitamins was stored in the dining room cupboard, which is easily accessible. LPA observed cleaning solutions stored, unsecured, under each of the two resident bathroom sinks.

At approximately 9:00AM, LPA reviewed 7 of 7 resident records and found 3 of 7 residents have not had a physician visit within the last 12 months. LPA observed 2 of 7 residents did not have current appraisals during this visit. LPA spoke with Licensee about physician reports and the requirements of when they need to be updated during the Post Licensing visit on 07/07/2025. LPA provided copies of regulation pertaining to resident records and incidental medical topics during that visit and issued a technical violation at the time. LPA reviewed medication records and observed there were no centrally stored medication lists for any resident. Medication was prepared for the day in small containers. Continued on LIC 809-C...