1. Were you at the facility when the onsite inspection was conducted? Yes No Not Applicable   If yes, are you: The licensee/representative? The administrator? Other?   Other Title: 2. Was the inspection process clearly explained to you upon the arrival of the licensing consultant/staff? Yes No N/A 2a. Comments 3. Were you treated with courtesy, dignity, and fairness by the licensing staff? Yes No N/A 3a. Comments 4. Did the licensing consultant/staff interview facility staff and residents? Yes No N/A 4a. Comments 5. Did the licensing consultant/staff interact respectfully with facility staff and residents? Yes No N/A 5a. Comments 6. Did the inspection interfere with the delivery of resident care? Yes No N/A 6a. Comments 7. Were facility staff comments about the inspection positive? Yes No N/A 7a. Comments 8. Were resident comments about the inspection positive? Yes No N/A 8a. Comments 9. If rule violations were identified, were you provided with technical assistance to assist you in meeting the requirements of the act and the rules? Yes No N/A 9a. Comments 10. Were you offered or provided consultation to assist you in developing methods for the improvement of service? Yes No N/A 10a. Comments 11. Did the licensing consultant/staff offer you positive comments? Yes No N/A 11a. Comments 12. Were you offered or provided an exit interview to review the inspection findings and given an opportunity to clarify incorrect or missing information? Yes No N/A 12a. Comments 13. Following the exit interview, did you have any unresolved disagreement with the application of the rules? Yes No N/A 13a. Comments 14. Was the onsite inspection completed in a reasonable amount of time? Yes No N/A   How long did the inspection take to complete? 15. Using the following scale, check the number that applies. The focused renewal inspection process was a meaningful and balanced assessment of our compliance with the rules and our quality of care provided to residents. 1 Strongly Disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly Agree   Any additional comments:   Name of licensing consultant/staff who conducted the inspection:   OPTIONAL: Please provide your contact information if we may contact you to discuss your comments.   Facility Name:   Your Name:   Your Phone #:   E-mail Address:   License #: