Routine inspection·August 26, 2025

On 8/26/2025 at 10:30 AM, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct 1-Year Annual Required inspection. LPA met Behavior Support Professionals (BSPs) Teresa Calderon and Susan Brinton, and explained the purpose of the visit. Susan phoned Administrator (AD) Kerri Nordstrom, who arrived around 11:00 AM. The facility’s fire clearance was approved for capacity of four (4) residents of which, two (2) may be non-ambulatory and two (2) ambulatory. Administrator Kerri Nordstrom, has an Administrator Certificate #6073133740 that expires on 12/3/2026. LPA toured facility with BSP Susan and AD including but not limited to bedrooms, bathrooms, kitchen, common area, backyard and garage. The facility consists of four (4) total bedrooms which 4 bedrooms are occupied by the residents and two (2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 108.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/12/2024. Emergency Disaster Plan was last reviewed on 8/1/2025. First aid kit was observed to be complete. Emergency disaster drill (fire and earthquake) was last conducted on 8/1/2025. LIC809-C Continued... LPA reviewed four (4) residents records. LPA reviewed six (6) staff records and 6 of 6 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications. LPA reviewed all four (4) clients P & I log. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/2/2025: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed LIC 500 Personnel Report - Reviewed LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.