Facility Evaluation Report

On 08/06/2025 Regional Manager (RM) Alycia Rayner and Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1 year annual inspection. RM and LPA met with Administrator Alina Jar and explained the purpose of the visit.

RM, LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: residents room, bathrooms, kitchen, storage area, and the common areas. LPA observed the facility to have two (2) days of perishable and seven (7) days of nonperishable foods. LPA and RM observed knives to be unlocked and accessible to residents in care. LPA and RM observed an open and unlocked storage shed which contained bleach in the backyard accessible to residents. LPA and RM observed medications unlocked in the fridge outside.

LPA conducted a file review of personnel and residents records. LPA observed personnel files to be incomplete. Staff had less than twenty (20) hours of annual training. Two personnel files were incomplete and missing Personnel record (LIC501) and Health Screening (LIC503).

LPA completed the full care tool and deficiencies was observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.