Facility Evaluation Report

On 4/30/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Licensee, Kelly Hentzen who was informed of the purpose of the visit. The facility has a fire clearance to serve six (6) non-ambulatory elderly residents of which one (1) may be bedridden. The facility also has an approved hospice waiver for four (4) and LPA was informed none of the residents are currently receiving hospice services.

LPA toured the facility with Licensee Hentzen and observed the facility is made up of a one-story home with five (5) resident bedrooms, two (2) bathrooms, a kitchen, dining area, living room, laundry room, and attached garage. Resident bedrooms had the required bedding, furniture, and lighting. Bathrooms had grab bars and non-skid mats in the showers. No bodies of water were observed on the premises. Indoor and outdoor pathways were free of obstruction. The facility had a two-day supply of perishable foods and seven-day supply of non-perishable foods. Medications and cleaning solutions/disinfectants are separately stored in different cabinets in the locked laundry room. LPA toured the garage and observed an additional food and emergency water. The facility has a room with additional incontinent supplies, blankets, linens, and pillows and emergency food. Licensee tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen last serviced on 3/17/2025. The facility's certificate of liability insurance expires on 5/1/2025. Staff present has a criminal record clearance and a valid first aid/CPR certification. Resident files reviewed had updated physician's reports and signed admission agreements. LPA reviewed the facility's Emergency Drill Participation Timesheet noting the facility's last fire drill was conducted on 3/22/2025. Long Term Care Ombudsman's contact information, complaint procedures, and facility sketch are visibly posted in a hallway. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee Hentzen.