Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with staff Krystal Boyles-Ambrecht. There are residents with a diagnosis of dementia and residents receiving hospice services. Required postings were observed.

LPA/staff initiated a tour of the facility at approximately 9:00 am and observed the following: Facility was a comfortable temperature and passageways were free from obstructions. Facility has a pool that is surrounded by a locked gate to ensure resident safety. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Water temperature in resident's bathrooms measured at 116.8, 114. 8 and 112.1 degrees F in bathrooms used by residents in care, which are within the range allowed by regulation. LPA/staff observed toilet handle was loose and staff fixed it immediately (technical violation issued). Toxins were inspected and are stored in the locked laundry room. At least two days of perishable and one week of nonperishable food was available. Fire extinguishers were last inspected May, 2025. Smoke alarms throughout the facility and carbon monoxide detector were tested and operational. Last disaster drill conducted on 7/24/2025.

At approximate 9:15 am during tour of the facility LPA/staff discovered a monitor outside of bedroom# 3. Additionally, LPA reviewed the facility house agreement and there is no information regarding the use of a monitor. Per staff, resident's responsible party brought the device because they used to monitor resident when they were at their home. Staff removed and discarded the monitor immediately. Continue on LIC809C...