S M RICK SNYDER DEPARTMENT OF LICENSING AND REGULATORY ...

RICK SNYDER STATE OF MICHIGAN MIKE ZIMMER

GOVERNOR DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR

BUREAU OF COMMUNITY AND HEALTH SYSTEMS

September 14, 2015

Vickie Clayton
Hillman's Haven LLC
333 Lynn St
Hillman, MI 49746

RE: License #: AL600269136
Hillman's Haven
200 Elizabeth
Hillman, MI 49746

Dear Ms. Clayton:

Attached is the Licensing Study Report for the above referenced facility. The study has
determined substantial compliance with applicable licensing statutes and rules. Your
Adult Foster Care large group home license is renewed. The regular license is valid
only at your present address and is nontransferable.

Please contact me with any questions. In the event that I am not available and you
need to speak to someone immediately, you may contact the local office at (517) 284-
9720.

Sincerely,

Marcia S. Elowsky, Licensing Consultant
Bureau of Community and Health Systems
Suite 11
701 S. Elmwood
Traverse City, MI 49684
(231) 342-4924

MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
BUREAU OF COMMUNITY AND HEALTH SYSTEMS
RENEWAL INSPECTION REPORT

I. IDENTIFYING INFORMATION AL600269136
License #:
Licensee Name: Hillman's Haven LLC
Licensee Address:
200 Elizabeth St
Licensee Telephone #: Hillman, MI 49746
Licensee Designee:
Administrator: (989) 742-7788
Name of Facility:
Facility Address: Vickie Clayton

Facility Telephone #: Vickie Clayton
Original Issuance Date:
Capacity: Hillman's Haven
Program Type:
200 Elizabeth
Hillman, MI 49746

(989) 742-2699

02/17/2005

20

AGED
ALZHEIMERS

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II. METHODS OF INSPECTION

Date of On-site Inspection(s): 09/11/2015

Date of Bureau of Fire Services Inspection if applicable: 07/22/2015

Date of Health Authority Inspection if applicable: 05/20/2015

Inspection Type: Interview and Observation Worksheet

Combination Full Fire Safety

No. of staff interviewed and/or observed 6
2
No. of residents interviewed and/or observed

No. of others interviewed 1 Role: Hospice Aide

• Medication pass / simulated pass observed? Yes No If no, explain.

• Medication(s) and medication record(s) reviewed? Yes No If no, explain.

• Resident funds and associated documents reviewed for at least one resident?
Yes No If no, explain.

• Meal preparation / service observed? Yes No If no, explain.

• Fire drills reviewed? Yes No If no, explain.

• Fire safety equipment and practices observed? Yes No If no, explain.

• E-scores reviewed? (Special Certification Only) Yes No N/A
If no, explain.

• Water temperatures checked? Yes No If no, explain.
Forgot

• Incident report follow-up? Yes No If no, explain.

• Corrective action plan compliance verified? Yes CAP date/s and rule/s:
N/A N/A

• Number of excluded employees followed-up?

III. DESCRIPTION OF FINDINGS & CONCLUSIONS
The facility is in compliance with all applicable rules and statutes.

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IV. RECOMMENDATION

I recommend issuance of a regular license to this AFC adult large group home (capacity
13-20).

09/14/15

_______________________________________

Marcia S. Elowsky Date

Licensing Consultant

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