Facility Evaluation Report

At 9:28am, on 8/12/2025, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 07/01/2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with Lead Staff Kevin Schaefer and explained the reason for the visit. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations.

At 9:35am, LPA and Lead Staff Kevin Schaefer conducted a walk through of the facilities first floor where residents reside, the second floor is only accessed by facility staff. LPA observed four (4) residents were in chairs in the family room watching TV and the fifth resident was in bed in their room. Resident rooms were observed to be furnished appropriately with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. At 9:48am LPA observed an aerosol can of Raid bug spray and a can of Pledge furniture cleaner sitting out on bookshelves in the family room accessible to residents and at 9:52am an aerosol can of Favor furniture cleaner and Clorox disinfectant mist left out in the living room next to the TV accessible to residents in care. This facility fire clearance allows for a bedridden resident in bedroom #3. LPA interview revealed Resident #1 (R1) requires assistance from staff with turning or repositioning, meaning R1 meets the bedridden definition in Title 22 Regulations for this facility type and R1 does not reside in bedroom #3. The facility has battery operated smoke detectors in each bedroom and the hallway leading to bedrooms that are all working, the carbon monoxide detector is in the hallway and functioning normally.