Facility Evaluation Report

At 10:20 AM on 8/21/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by a caregiver. The LPA identified herself, explained the purpose of the visit, and requested to meet with the Administrator. A caregiver called the Administrator to inform her that the LPA was on site to conduct an annual inspection. The Administrator arrived at the facility at 10:30 AM and an inteview followed. The Administrator accompanied the LPA on a tour of the facility.

This facility is licensed to serve six non-ambulatory residents and has a hospice waiver for six. The facility is a five-bedroom, 2-bathroom house located in a residential area. The census was four residents at the time of this site inspection, all of whom were at the facility at the time of the site inspection. There were two staff on duty when the LPA arrived at the facility.

The LPA toured the inside of the house, including the bedrooms, bathrooms, kitchen, dining room, living room, laundry room and garage. The entire house was clean, odor-free, and pest-free. The windows and window screens were in good repair. The required documents were posted in the entry way and front room.

The LPA toured the four resident bedrooms and one resident bathroom. There are two double-occupancy bedrooms and two single-occupancy bedrooms. Each bedroom contained the required furniture, including bed, bedside table, lamp, dresser, and chair. The LPA toured the bathroom. The bathroom contained grab bars, non-slip surfaces, and assistive devices. The LPA measured the water temperature at a bathroom sink. The temperature of the water was 120 degrees Fahrenheit, within the required range. The Administrator stated that staff tested the water temperature daily. (Continued on LIC 809-C)