Facility Evaluation Report

Licensing Program Analyst (LPA) KaSandra Lopez conducted a pre-licensing visit to the above noted facility. The LPA met with applicants Helen Rose Busch and Johnna Udden. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver for six has been requested. Component III was conducted with the applicants after the physical plant tour of the facility.

The facility is a single story home. At 9:15 AM, a physical plant tour was conducted inside and out. The is a table at the entry of the facility for screening of visitors. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents and one (1) bedridden residents in bedroom #5. The facility has one (1) private resident bedrooms (bedroom #2), three (3) shared bedrooms (bedrooms #1, #5, & #6), one (1) staff bedroom (bedroom # 4), and one (1) extra bedroom (bedroom #3) which can be used as an isolation room. Two bedrooms have direct exits outside. All resident rooms were furnished appropriately, although bedroom #1 is lacking closet space. The beds are furnished with a comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. All rooms were free of odors. All window screens were clean and maintained in good repair.

There is one bathroom in the hallway and two private bathrooms in bedroom #5 and bedroom #6. The resident bathrooms have a showers with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms measured at 110 degrees F.

Resident and staff records are stored in a locked cabinet which is currently located in the kitchen/dining area. Medications are centrally stored in a locked cabinet in the kitchen/dining area also. The first aid supplies were complete, including a thermometer and a current version of a first aid manual and currently stored in the garage.