Facility Evaluation Report

At 9:45 AM on 8/13/2025, 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 asked to meet with the Designated Facility Administrator (DFA). The LPA spoke with the DFA on the phone. The DFA authorized her representative, designated on the LIC308, to assist and accompany the LPA on a tour of the facility and records review. The designated representative arrived at the facility at 10:30 AM.

This facility is licensed to serve six non-ambulatory residents. It has a hospice waiver for six residents. Its fire clearance was issued by Oakdale Fire Department Station 27 on 04/10/2024. The census was four residents at the time of this inspection. There was one caregiver on duty.

The LPA toured the inside of the house, including four resident bedrooms, the kitchen, two bathrooms, dining room, living 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, including the license, current administrator certificate, personal rights, complaint hotline poster, and ombudsman information.

The LPA inspected three smoke detectors, a carbon monoxide detector, and fire extinguisher. The smoke detectors were in the bedroom hallways and were an interconnected system. Staff tested one smoke detector and all three detectors sounded an alarm. Staff tested the carbon monoxide detector and it sounded an alarm. The fire extinguisher was last serviced on 3/28/2025 by Assured Fire Extinguisher Service. The LPA observed documentation of quarterly disaster drills.

This report continues on LIC809-C, page 2.