Routine inspection·July 22, 2021

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 07/22/2021 at 12:11pm. LPA met with facility Administrator Tami Ojwang (Admin). LPA toured the facility, including front office, medicine room, dining room, garden room, mansion, activities room, laundry room, salon, 2 bathrooms, courtyard, 3 resident rooms, and 3 resident bathrooms. All staff members observed to be wearing masks. Admin confirmed that all but 2 residents and 5 staff members have been vaccinated. Facility policy has been updated to only employ vaccinated staff by August 1st. Facility Mitigation plan has already been submitted and approved. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility noted to possess a 30-day supply of PPE. Facility observed to have designated entry point. Staff took LPA's temperature, and screened for symptoms. All restrooms stoked with paper towers. Hand washing signs observed in all bathrooms. Social distancing signs not observed to be posted throughout facility in all public areas. All bathrooms observed to have lidded trash cans. LPA observed water temperature in 3 resident bathrooms. After approximately 2 minutes of heating up, 1 resident room observed to have hot water temperature of 136.4*F, while 1 additional resident restroom noted to have hot water temperature of 140.3*F. Advisory notes issued and deficiency cited. See 809-D. This report reviewed with Administrator Tami Ojwang and a copy of the signed report was provided.