Routine inspection·July 23, 2025

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Administrator Melissa Deussen. The facility's license shows a maximum capacity of six (6), two (2) of which may be ambulatory, two (2) non-ambulatory, and two (2) bedridden. Approved room for non-ambulatory is the foyer and bedridden approved for bedridden to reside in back bedroom of the living room. Additionally, the facility is approved for four (4) hospice waivers. During today’s inspection there were four (4) residents in care. LPA and Administrator Deussen toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: 1st floor Bathroom sink 1 was 113F and bathroom 2 read at 116F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients.  Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Deussen, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. When inspecting the facility's fire extinguishers, LPA noted that there was no service tags on the extinguishers. Administrator Deussen stated they purchase new extinguishers annually but did not retain the receipt. As date of purchase could not be verified, a deficiency is being cited per Title 22 regulations and noted on the attached LIC 809D. In addition, a Civil Penalty is being assessed for a Zero Tolerance Violation regarding Fire Safety and are noted on the attached LIC 421IM in the amount of $500. LPA interviewed one (1) staff and zero (0) clients, and interviews did not reveal any licensing or regulatory concerns. LPA observed residents to be treated with dignity and care. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. One deficiency was cited during the inspection. An exit interview was conducted with Administrator Deussen to whom a copy of this report, the LIC 421IM, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.