Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual Inspection. LPA met with Sandra Soth Program Manager.

LPA and SS toured the facility including but not limited too, activity rooms, a common area, kitchen area and facility bathrooms. LPA observed the rooms were clean, organized and in good repair. Hot water temperature measured at 118.5 degrees F. in bathroom. The facility provides snacks throughout the day for the clients. Fire drill was last conducted on 6/18/2026. The facility does administer medications currently for clients and controls P& I monies for clients.

Exits were observed to be accessible to clients and free from obstructions. LPA observed smoke alarms interconnected with the fire department. Fire extinguishers were serviced and current for 2026. There was a required ABC extinguisher in the FACP room, extinguisher to be placed in the break room and the fire risers are out of compliance. The riser are missing the annual and the five year sticker.

First aid kit observed to be complete. LPA reviewed 10 client and 8 staff files including three drivers. During the file review for the resident LPA observed outdated medication for R2 and no restricted health care plan for R1.

Deficiencies were cited on today's inspection. Advisories given.

An exit interview was conducted and appeal rights given.