Routine inspection·September 29, 2025

Licensing Program Analyst (LPA) Hansen, arrived unannounced to conduct an Annual Inspection of facility and was welcomed by Janette (caregiver), Administrator, Eric Moessing was contacted by staff and arrived during inspection. Facility is a single story RCFE with 13 bedrooms and a fire clearance for 15 Non ambulatory of which 2 may be bedridden. Facility granted hospice waiver for 6. There is currently a total of 13 residents, 6 of which have dementia diagnosis, with 1 resident currently under Hospice care. On 9/29/2025 at approximately 9:30 AM LPA initiated a tour of the facility with staff and made the following observations: Facility was a comfortable temperature and all exits were free from obstructions. Activity calendar observed and menus posted. Required postings were observed. Resident rooms were furnished per regulation. Water temperature in resident's bathroom faucets measured between 108.3 degrees F and 116.2 degrees F within Title 22 acceptable range of 105 to 120 degrees F in 7 out of 7 resident’s bathroom faucets. Extra hygiene products and linens were available. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. Toxins are in locked cabinet in hallway closet, under kitchen sink & in locked laundry room. Medications are centrally stored in the medication cabinet in the kitchen which was locked at the time of inspection, overflow of medications are stored in 2 locked cabinets in family room. Fire extinguisher was last inspected 10/11/2024. Facility has sprinkler system and hard-wired smoke alarm system that is maintained by vendor, last service was conducted 7/14/2025. Combination Smoke alarm and Carbon Monoxide detectors tested and found to be working. Auditory alarms were functional at the time of visit. Continue on LIC809-C Continue from LIC809 File review was initiated at 11:00 am. Five staff files and five resident files along with 2 resident medication records were reviewed. Five resident records were reviewed finding all but 1 resident have current needs and service plans updated (see LIC9102 TA) and all residents have Physicians Assessments per regulations. At approximately 12:20PM staff records were reviewed. All staff requiring background checks have been cleared and associated to facility. All staff have required training and other required documents. All staff have required First Aid and CPR certificates. At approximately 1:20 PM Medications of 2 out of 2 residents were found to be given according to physician’s directions. Centrally Stored Medication Records (CSMR) were found to be complete and accurate on 9/29/2025. Disaster Drills are conducted quarterly and different shifts, with the last one being conducted on 9/16/2025. Administrator Certificates for Eric Moessing, 7005070740, expires 8/16/2026. No citations given during today’s inspection. LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/17/2025: LIC 308 Designated (if changes) LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance