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. Were the materials and information provided to you prior to the onsite inspection sufficient for your preparation? Yes No N/A 2a. Comments 3. Was the inspection process clearly explained to you upon the arrival of the licensing consultant/staff? Yes No N/A 3a. Comments 4. Were you treated with courtesy, dignity, and fairness by the licensing staff? Yes No N/A 4a. Comments 5. Did the licensing consultant/staff focus primarily on observations and interview of staff and residents to determine if the supervision, protection and personal care needs of residents were being met? Yes No N/A 5a. Comments 6. Was the scope of the inspection expanded as a result of the observations made and interviews conducted? Yes No N/A 6a. Comments 7. Did the licensing consultant/staff interact respectfully with facility staff and residents? Yes No N/A 7a. Comments 8. Did the inspection interfere with the delivery of resident care? Yes No N/A 8a. Comments 9. Were facility staff comments about the inspection positive? Yes No N/A 9a. Comments 10. Were resident comments about the inspection positive? Yes No N/A 10a. Comments 11. 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 11a. Comments 12. Were you offered or provided consultation to assist you in developing methods for the improvement of service? Yes No N/A 12a. Comments 13. Did the licensing consultant/staff offer you positive comments? Yes No N/A 13a. Comments 14. 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 14a. Comments 15. Following the exit interview, did you have any unresolved disagreement with the application of the rules? Yes No N/A 15a. Comments 16. Was the onsite inspection completed in a reasonable amount of time? Yes No N/A   How long did the inspection take to complete? 17. Do you believe this focused onsite inspection process provided the licensing consultant/staff with an accurate assessment of your facility? Yes No N/A 17a. Comments 18. Is there anything else that you believe the licensing consultant/staff should have evaluated? Yes No N/A   Please describe: 19. Do you prefer this focused onsite inspection process over the standard inspection process used in your facility previously? Yes No N/A 19a. Comments 20. 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:   Your Name:   Contact Phone #:   E-mail Address:   Facility Name:   License #: