Routine inspection·July 15, 2025

License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required Annual inspection of the facility. LPA was welcomed by staff Elia Cuevas who contacted Licensee Kelly Eriksen that arrived shortly after. Facility is a single story 5 bedroom RCFE with a fire clearance for 6 Non ambulatory of which 1 may be bedridden. Currently there is 5 residents at the facility, 2 with a diagnosis of dementia and 2 currently on Hospice. LPA toured the facility on 715/2025 at approximately 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 1/12/2025 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 106.3 degrees F and 109.2 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 was properly stored as per regulations on this day at the time of the visit. Toxins are stored locked under the sink in 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 slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. All bedrooms have lighting & appropriate furnishings per Title 22 regulations. Continue on LIC809-C Continued from LIC809 A review of five resident & five staff records as well as two resident medications was conducted. LPA reviewed resident’s files at 8:45 AM on 7/15/2025 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 closet in living room, overflow of medication in office cabinet. At approximately 10:30am a sample review of 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 9:30 AM on 7/15/2025 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 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 expired on 3/7/2025, LPA observed documents submitted for updated certificate. Licensee Kelly Eriksen /Administrator Certificate 7008387740 expires 11/5/2025. Facility has live music twice a week, they take residents to the senior center weekly, as well as activities of exercises and games. Disaster Drills have been conducted quarterly with the last one being conducted on 4/18/2025. Facility has portable generator in case power goes out. There were no deficiencies cited at this time. LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 7/31/2025: 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