Routine inspection·February 6, 2025

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator Kelly Eriksen arrived later. Facility has 6 residents with 4 having dementia diagnosis. Facility has fire clearance for 6 Non Ambulatory with 1 bedridden. Facility currently has two residents on hospice and facility has a Hospice Waiver for six. At approximately 8:15 am LPA and staff toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. LPA observed locked kitchen cabinet containing cleaning supplies and sharp knives. All bedrooms were equipped with lighting/lamp, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required slip resistant mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 114.9 to 118 degrees F, within the allowable range of 105 to 120 degrees F. Fire extinguishers were observed to be charged. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 11/14/2024. Facility has a backup generator for use during a power outage. At approximately 8:45 am on 2/5/2025 LPA conducted a review of five resident files and learned that 5 of 6 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A). Continued on 809C... Continued from 809... At approximately 9:25 am on 2/5/2025 LPA conducted a review of six out of ten staff files and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements are current and LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed. At approximately 10:00pm LPA and Admin conducted a spot check of medication and medication records. No discrepancies observed. Medication is centrally stored in a locked closet in the hallway. Kelly Eriksen Administrator Certificate 7008387740 expires 11/5/2025. All fees are current. LPA and Admin discussed facility's Infection Control Plan and Emergency Disaster plan. Exit interview conducted & copy of report left No deficiencies cited during today's inspection LPA Hansen has requested the following documents updated and submitted to CCL by 2/21/2025. LIC500- Personnel Report LIC308- Designation of Responsibility (if changes) LIC9020 Register of Facility Residents Administrator Certificate Emergency Disaster Plan (if changed) Copy of Current Liability Insurance