Facility Evaluation Report

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Continuation Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Administrator Pontius Malmberg. The facility was licensed for a capacity of six (6) non-ambulatory residents and approved for a hospice waiver for four (4) residents.

Administrator Diep Malmberg arrived during the visit and assisted the LPA. During today's visit the LPA reviewed additional records and conducted interviews. Technical advise was provided and deficiencies were cited in an LIC 809D page. A plan of correction was jointly formulated with Administrator Diep Malmberg.

An exit interview was conducted with Administrator Diep Malmberg, to whom a copy of this report, LIC 811, LIC 809D, and the Licensee/Appeal Rights (LIC9058), were provided.