Facility Evaluation Report

On 07/07/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Executive Director Brigitta Lofvendahl and explained the purpose of the visit. At the time of the inspection there were 2 staff and 14 residents present. The facility is licensed to serve residents age 60 and over, 15 non ambulatory of which 15 may be bedridden. The facility has an approved hospice waiver for six (6). There are currently (0) resident's receiving hospice services, and (0) bedridden residents.

The facility was observed to be clean and clutter and odor free. The call lights tested and were observed to be operable. The facility food supply was sufficient, as there was a 2 day supply of perishable and a 7 day supply of non perishable food items. LPA observed for the medications and all toxic chemicals and other hazards/sharps to be inaccessible to residents. There are no pools or bodies of water on the premises. The hot water temperature was tested and found to be within regulatory limits, measuring between 116-118.7 degrees Fahrenheit. The facility has fire extinguishers were last serviced on 03/27/25. The emergency drills are conducted quarterly which also included elopement drills, the last drill was conducted on 4/21/25. The last fire inspection was conducted on 11/15/24.

LPA conducted a review of both staff and resident records and observed the following for all staff present to have obtained criminal record clearance and to be associated to the facility. Staff were also observed to have current CPR/First Aid training, and for the Executive Director to possess a valid Administrator certificate which expires on 04/16/27. Resident files were observed to have the required documentation appraisal, admission's agreement and physician's report. The governing body was observed to be in good standing. Based on today's inspection, no deficiencies were observed during today's visit.

An exit interview was conducted and a copy of the report and LIC 811 was provided to the Executive Director,Brigitta Lofvendahl.