Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Julia Goker.

The facility has a licensed capacity of 6 non-ambulatory residents, 1 of which may be bedridden in bedroom #4 and has a hospice waiver for 6 residents. During today’s visit, the facility had a census of 5 non-ambulatory residents, 3 of which were receiving hospice services. The Administrator for the facility is Julia Goker and their certificate was valid and current.

During today’s visit, LPA inspected each room of the facility, including resident and staff rooms, private and common bathrooms, kitchen, garage, common areas, and outside space. No bodies of water, delayed egress, or secured perimeter were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed linens and hygiene products for resident use. The facility’s ambient and water temperature were measured within regulatory requirements at multiple locations. LPA observed locked storage for resident medications and hazardous and/or toxic chemicals, both of which were stored separately from food supplies. According to Julia Goker, no firearms or weapons are stored on the premises. LPA observed a minimum supply of 2-days of perishable food and 7-days of non-perishable food. The refrigerator and freezer temperatures were kept within requirements. Staff present at the facility had a criminal background clearance and association. LPA reviewed multiple resident and staff records.

No deficiencies were cited on today’s date. An exit interview was conducted with Administrator Julia Goker, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).