Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and explained the purpose of the visit. Later joined by Administrator Jennifer Wigon.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 123.5 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. However the Ansul system and the Riser's Five year inspection is expired and both systems needs to be serviced. This is a zero tolerance fire clearance violation. LPA observed centrally stored medications for each resident. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 15 resident and 4 staff files, including criminal record clearances. During the resident files review LPA observed 3 outdated (LIC 602) Physician's Reports Fire drill was completed on 5/10/2022.

All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. Exit interview conducted appeal rights given.