Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents of which one may be bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 6 residents, with 3 residents on hospice. Administrator Roy Moeller has a valid certificate that expires on 10/21/2027. Administrator provided updated liability insurance and LIC 500 during the visit.

LPA along with Administrator Moeller toured the facility at 7:58 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 resident bedrooms, living room, dining room, staff room and kitchen as well as 7 restrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.8 degrees F and 114.8 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the emergency disaster plan and plan is complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 10/15/2025. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise. CONTINUED ON LIC 809C DATED 11/06/2025