Routine inspection·October 9, 2025

On October 9, 2025, at 12:45 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (ADMIN) Muktar Mohamed and explained the purpose of the visit. The facility is licensed to operate six (6) non-ambulatory of which one (1) maybe bedridden, and have a hospice waiver for six (6) residents. The facility is a single-story building located in a residential neighborhood. It consists of the following: three (3) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living area, dining area, kitchen, attached 2-car garage, and an outside covered patio area. There is a unit attached on site that is dedicated to staff residency. and another unit that is attached to the facility that is dedicated as the licensee’s residency. Currently, there are no residents residing at the facility. LPA Kim toured indoor and outdoor of the physical plant with ADMIN Mohamed. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, and Resident Room 3. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 116.0 degrees F and 117.6 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The facility has one (1) fire extinguisher that is charged and mounted in the living area. All smoke/carbon monoxide detectors were operable. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the PUB475 posted in the living area measured at 8.5" X 11". LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). A working telephone (612-205-5094). First Aid Kit contained all the necessary elements. LPA conducted an audit staff files (S1) which was in order and complete. . A technical violation was assessed during the visit. LPA observed PUB475 posted in the living area measured at 8.5” x 11”. An exit interview was conducted, and a copy of this report and LIC9102 were provided to Administrator Muktar Mohamed.