Facility Evaluation Report

On 7/26/22, Licensing Program Analysts (LPAs) V. Gorban and LPM S Moua conducted an unannounced Annual Required Infection Control Inspection. LPAs allowed entrance through designated entry point. Visitor sign-in book available upon entry. LPAs conducted facility tour with Administrator Stacey.

Facility toured. Most bedrooms are single occupancy. Residents present during today's inspection observed to be participating in sitting in dining areas and taking a walk. Kitchen toured. LPA observed facility to have a 7-day supply of non-perishable food of a 2-day supply of perishable food available. Medications are locked and secured; residents observed to have a 30-day supply of medication available. PPE is locked and secured and available if necessary. Back yard and garage was toured and facility has self latching gate No obstructions observed.

Smoke detectors observed to be operational during today's inspection. Fire extinguishers present with a service date of 05/20/2022.

Administrator to submit updated required additional documents including, LIC 500 Personnel Report, and LIC 610 Emergency Disaster Supply no later than 08/18/2022

Exit interview conducted. Report signed on site and a copy provided to Licensee for facility records.