Facility Evaluation Report

On 9/8/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Kristin Uthman, Human Resources. Andy Frisch, Executive Director/Administrator arrived later during the visit.

LPA toured the physical plant. This is a two story building with 9 bedrooms and 4 bathrooms. All bedrooms were observed to have the required furniture and sufficient lighting. The facility's fire extinguishers were last checked on 5/20/2025 and were observed to be fully charged. The facility had night lights in the hallways. The facility's smoke and carbon monoxide alarms were observed to be in working order. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The First Aid kit had all the required articles.

LPA reviewed 7 resident files and 6 staff files. All were observed to be complete.

LPA also reviewed Personal and Incidental (P&I) monies kept at the facility which matched the facility records.

LPA Calandra reviewed Centrally Stored Medications Records(CSMR). A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

A Technical Violation was provided for the hot water temperature being measured at 134 degrees Fahrenheit. The hot water tank temperature was turned down in the presence of the LPA.