Post-licensing visit·June 5, 2025

On 06/05/2025 Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Post-Licensing Inspection of facility and was welcomed by staff Alberto Lopez. Staff contacted Administrator Kelly Eriksen who arrived during inspection. Facility is a single-story building with 6 bedrooms, and an approved fire clearance for 6 Non-Ambulatory of which 1 may be bedridden. Hospice waver has been granted for 2. There are currently 6 residents with 1 using Hospice services during the time of this inspection. Facility tour/inspection began at 8:10 AM: LPA toured the indoor and outdoor portions of facility on 6/05/2025; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility has special care plan of operation and programming for residents with dementia. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing, as well night lights for residents. 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. Food is available for residents any time of the day. Cleaning products, sharp items, other toxins and chemicals are kept out of resident access and found secured and stored in the kitchen, laundry room, and shed. There was a supply of cleaners, hygiene products and paper products available for residents. Resident bathrooms had required slip resistant mats and grab bars. Hot water temperature measured between 111.7 degrees F and 115.8 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathroom faucets. All bathrooms at the facility were supplied with paper towels and hand soap. Continue on LIC809-C Continued from LIC809 Fire Extinguisher was found to be last charged on 2/12/2025. Smoke detectors and Carbon monoxide detectors were tested and found to be operational. Facility has video surveillance in common areas, that does not include audio. The back porch of the house has shade and provides a safe and secure area for residents to spend time outside. File Review began at 9:30 AM: A review of six residents & sample review of five staff records as well as two resident’s medications was conducted. LPA learned that 6 out of 6 residents have updated reappraisal/needs & care plan as well as medical assessments. Sample review of 5 staff records revealed staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. All direct care staff have received the additional training requirements; LPA was also provided required proof of CPR & 1 st Aid certification. Medication Audit began at 11:00 AM: Medications were centrally stored in locked hallway closet/ medication room. LPA observed medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to have all medications entered for residents. LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills will be conducted quarterly and in different shifts with the last one being conducted on 4/18/2025. Facility has 1 large generator that can power ¾ of the house in case of power outage. In addition, Kelly Eriksen, Administrator Certificate # 7008387740 expires 11/5/2025. LPA has requested Licensee to submit Liability Insurance, LIC308 (Designee), & LIC 500 (Personnel Report) to CCL by 6/20/2025. No deficiencies found. No citations issued.