Facility Evaluation Report

On 10-7-22 at 9:48am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to an incident report dated 9-18-22. LPA met with Administrator Nellen Van De Pol and explained the purpose of the visit. LPA reviewed incident report with Administrator and interviewed Administrator. LPA also conducted a health and safety check of home. Incident report states resident1 (R1) signed out of facility log book on 9-15-22 at 5:35am and checked self into hospital. Incident report states R1 has had multiple episodes of checking self into hospital. Incident report further stated Administrator will issue a 30-day notice to R1. It was determined based on interview and record review that a copy of Eviction notice was received by licensing department within 5 days of issuance to R1. LPA observed a fax confirmation of notice sent on 9-19-22 to licensing department and R1s responsible person. Additionally, LPA reviewed updated needs and service plan reflecting R1's behavior.

During health and safety check, LPA observed excessive amounts of flies throughout facility including kitchen, common area, and resident bedrooms. Additionally, LPA observed sliding screen for sliding door in resident2 (R2) room to be malfunctioning and containing spider webs and excessive dirt.. Facility temperature was 76*F. No obstructions to fire exits observed today. There are a total of 6 residents currently residing in facility; one staff member and Administrator were on duty during LPA's visit. LPA observed adequate food supply available for residents in care.

Based on today's visit, citations are issued under Title 22, Division 6. An exit interview was conducted with Nellen Van De Pol and a copy of this report was left with Nellen. Appeal rights explained and to be emailed.