Facility Evaluation Report

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director (ED) Natalie Carlborg. The facility serves 214 residents ages 60 and above, of which 23 are ambulatory and the remaining residents may be non-ambulatory, including 25 bedridden. Delayed egress was approved in building C1. Hospice waiver was approved for 25 residents. During today’s inspection, there were a total of 102 residents in care. This facility does feature a secured perimeter.

LPA and ED toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. A pool was present at the facility. The pool fence was at least 5 feet high and the fence did not obstruct the pool from view. The gates to enter the pool were self-latching. Per ED, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and delayed egress doors were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) and Personal Protective Equipment were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.

No deficiencies were cited during the inspection. An exit interview was conducted with ED to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.