Routine inspection·June 4, 2024

License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required Annual inspection of the facility. LPA was welcomed by staff who contacted Licensee/Administrator Kelly Eriksen who arrived shortly after. There is a total of 5 residents at the facility, currently 2 with a diagnosis of dementia. There are 2 residents currently on Hospice. LPA toured the facility on 6/4/2024 at 8:30 AM with staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility serves residents with dementia and has a plan of operation for special care and programming. Exits were equipped with auditory devices which were activated and working properly at the time of the visit. Fire Extinguishers were found to be last charged on 1/29/2024 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 112.2 degrees F and 113.9 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility. 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 per Title 22 regulations. A review of five resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 9:00 AM on 6/4/2024 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. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 6/4/2024 at 11:00 AM. Continue on LIC809-C Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPA reviewed a sample of staff records at 10:15 AM on 6/4/2024 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 3/7/2025. LPA reviewed Licensing Information System (LIS) with Licensee Kelly Eriksen who stated that is correct 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 5/27/2024 There were no deficiencies cited at this time, on this day of inspection. LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 6/30/2024: LIC 308 Designated (if changes) LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance