Routine inspection·October 9, 2025

On 10/09/2025 at 9:53AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Administrator, Nicolette Lake and explained the purpose of the visit. The Administrator currently holds a certificate (#7014095740) expired on 10/04/2025, certificate is being processed and is in pending status per CCLD portal. The facility’s fire clearance was approved for five (5) non ambulatory residents and one (1) bedridden resident. LPA toured facility with Nicolette including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 bedrooms in total and four (4) bathrooms. ADL unit in the backyard is occupied by Administrator. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the residents shared and private bathrooms were measured at 110.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7-day supply of nonperishable and 2 days of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents . Continue on LIC809C Continued from LIC809 Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/07/2025. Emergency Disaster Plan was last posted on 10/09/2025. First aid kit was observed to be complete. LPA reviewed all six (6) resident records, four (4) staff records and they were all complete. LPA also reviewed medications and MAR during visit. The following forms are to be updated and submitted to CCLD by 10/16/2025: LIC 500 Personnel Report LIC 400 Affidavit Regarding Client/Resident Cash Resources LIC 402 Surety Bond LIC610E Emergency Disaster Plan LIC308 Designation of facility responsibility No deficiencies observed during visit. Exit interview conducted and a copy of this report provided to Nicolette Lake .