Routine inspection·May 4, 2023

License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required Annual inspection of the facility. LPA was welcomed by Licensee/Administrator Kelly Eriksen. There is a total of 5 residents at the facility, currently non with a diagnostic of dementia. There are 2 residents currently on Hospice. LPA toured the facility on 5/4/2023 at 10:20 AM with Kelly Eriksen Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices which were activated and working properly at the time of the visit. Fire Extinguisher was found to be last charged on 12/7/2022 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 113.3 degrees F and 118 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored locked under the sink in a kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307. A review of five resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 1:00 PM on 5/4/2023 and learned that 5 of 5 residents have an updated reappraisal/needs & care plan, TB and physician’s assessments on file as required by Title 22 Regulation. Medications were centrally stored in locked cabinets in the facility office by living room of the facility. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 5/4/2023 at 1:20 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. Continue on LIC809-C LPA reviewed a sample of staff records at 1:40 PM on 5/4/2023 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at the facility have received the additional training requirements. LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed. Kisa Doss Administrator Certificate # 6007381740 expires on 3/7/2023. LPA reviewed Licensing Information System (LIS) with Licensee Kelly Eriksen who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have been conducted quarterly with the last one being conducted on 2/27/2023. In addition, facility is ensuring staff is trained monthly. There were no deficiencies cited at this time. LPA Hansen is requesting Licensee to update the following documents by 5/19/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance