Routine inspection·December 31, 2025

At 9:45am, on 12/31/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee Evelyn Strampe, announced who he was and the reason for the visit. Licensee and LPA conducted a full tour of the facility. This facility is a single story residential home with five resident bedrooms (one is dual occupancy), two full bathrooms. There is a living room with dining space and a kitchen. There is access to the laundry area off the kitchen as it also gives access to an emergency exit and one of the full bathrooms. At 9:57am in the laundry area LPA observed an open package of laundry detergent pods, two aerosol cans of Lysol disinfectant and bottles of rubbing alcohol not locked up accessible to residents; at 10:05am in the kitchen LPA observed medications not secure in the refrigerator and a sharps container with used syringes with needles not secure sticking plunger side up out the top of the sharps container accessible to residents in care; at 10:11am in a dresser behind the living room couch LPA observed approximately 9 bottles of the Licensees personal medications not locked up accessible to residents in care; and at 10:26am in the backyard on the south side of the facility a half bottle of Clorox stain remover and half bottle of hair & grease drain opener also accessible to residents in care. LPA observed boxes and clothing blocking the emergency exit off the laundry area and a night stand blocking the emergency exit off the bedroom to the left of the front door of the facility. LPA noted that the backyard and the front yard both have seating and shade for residents and visitors. LPA noted fresh fruit in the kitchen for residents to enjoy. LPA tested facility hot water at 109*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2 - days of perishable and at least 7 - days of nonperishable foods. (Continued on LIC809-C) LPA conducted a resident record review finding four of the six residents are at risk if given direct access to hazardous items (disinfectants, poisons, etc.) and LPA observed three of those four residents walk independently in the facility during the visit. During resident record review Licensee admitted they use a gait belt to keep Resident #1 (R1) in a recliner in the living room to prevent the resident from wandering or getting up to go out a door. LPA reviewed with the Licensee that this is a restraint and cannot be used for this purpose. LPA cited a deficiency and the Licensee stated they will not restrain the resident further. Resident record review also revealed Resident #2 (R2) is considered bedridden and this facility does not have a fire clearance for a bedridden room. Licensee stated to LPA they have not seen R2 turn or reposition in bed independently recently as they provide R2 all mobility assistance and R2 likely cannot follow instruction to do so independently. LPA and Licensee conducted a partial review of the annual care tool modules. LPA will have to return to finish the annual visit at a later date. Exit interview conducted, deficiencies cited on LIC809-D pages, report signed, report and appeal rights provided to the Licensee.