Facility Evaluation Report

Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:30 a.m., the LPA met with Executive Director (ED) Ken Mahler and explained the reason for the visit.

RECORD REVIEW: Between 9:50 a.m. and 2:00 p.m., the LPA conducted a file review for nine (9) residents and eight (8) staff. Resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Disaster drill was last conducted on 01/18/2025. Administrator certificate is current and valid until 10/18/2025. Documentation: During the time of the visit, the LPA obtained a copy of the liability insurance, resident roster, staff roster, Infection Control Plan and Emergency and Disaster Plan.

Starting at 2:15 p.m., the LPA conducted interviews with three (3) staff and the ED.

At 3:20 p.m., the LPA along with the ED conducted a brief physical plant tour to ensure there are no health and safety hazards.

Due to time constraints the LPA will return to complete the annual at a later date.

Exit interview conducted. A copy of the report was provided.