Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen, arrived unannounced to conduct an Annual Inspection of facility and was welcomed by Janette (caregiver), Administrator, Eric Moessing was contacted by staff and arrived during inspection. Facility is a single story RCFE with 13 bedrooms and a fire clearance for 15 Non ambulatory of which 2 may be bedridden. Facility granted hospice waiver for 6. There is currently a total of 13 residents, 6 of which have dementia diagnosis, with 1 resident currently under Hospice care.

On 9/29/2025 at approximately 9:30 AM LPA initiated a tour of the facility with staff and made the following observations: Facility was a comfortable temperature and all exits were free from obstructions. Activity calendar observed and menus posted. Required postings were observed. Resident rooms were furnished per regulation. Water temperature in resident's bathroom faucets measured between 108.3 degrees F and 116.2 degrees F within Title 22 acceptable range of 105 to 120 degrees F in 7 out of 7 resident’s bathroom faucets. Extra hygiene products and linens were available. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. Toxins are in locked cabinet in hallway closet, under kitchen sink & in locked laundry room. Medications are centrally stored in the medication cabinet in the kitchen which was locked at the time of inspection, overflow of medications are stored in 2 locked cabinets in family room.

Fire extinguisher was last inspected 10/11/2024. Facility has sprinkler system and hard-wired smoke alarm system that is maintained by vendor, last service was conducted 7/14/2025. Combination Smoke alarm and Carbon Monoxide detectors tested and found to be working. Auditory alarms were functional at the time of visit.