Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Receptionist Hayley Josten. Executive Director Heather Myers arrived later during the visit. The facility's license shows a maximum capacity of one-hundred-and-twenty non-ambulatory residents, ten (10) of which may be bedridden. Bedrooms 110, 112, 123, 131, 134, and 207 are cleared for bedridden. Additionally, the facility has a hospice waiver for fifteen (15) and the first floor features delayed egress for the memory care unit. During today’s inspection there were seventy-nine (79) residents in care. Note, LPA did step out for lunch from 12:10-1:10pm.

LPA and Executive Director Myers toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms inspected contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Sink in 1st floor medication room read at 108.6F, common restroom sink on the 2nd floor read at 105F, and a resident unit sink on the 3rd floor read at 107.7F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.