Facility Evaluation Report

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED), Tracy Freudendahl. Facility provides care and assistance to Older Adults in Assisted Living. Fire clearance is approved for fifty-five (55) non-ambulatory and twenty-eight (28) ambulatory residents. There is an approved hospice waiver for seven (7) residents. The fourth (4th) floor of the facility houses an independent living population that rents apartment units on the property, these are not part of the Residential Care for the Elderly (RCFE) license. The facility has an emergency disaster plan as required. The facility has a required infection control plan. Upon arrival, LPA was informed that there were forty-four (44) residents in care. At approximately 9:25 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation.

At approximately 10:00 AM LPA toured the facility with ED Freudendahl. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offered a variety of menu options for the residents at each meal. Snacks are available for residents. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of ten (10) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. The call system was tested in a resident's room and Caregiver response time was under two (2) minutes.