Routine inspection·December 11, 2025

Licensing Program Analysts (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:45 a.m., the LPA met with staff and explained the reason for the visit. At 10:01 a.m., the Co-Administrator, Johnna Udden arrived at the facility. At 10:15 a.m., Administrator, Helen Rose T. Busch arrived at the facility. RECORD REVIEW: Between 10:02 a.m. and 11:30 a.m., the LPA conducted a file review for all five (5) residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All files were in order. The LPA observed documentation for the Infection Control Plan and Emergency and Disaster Plan. The last emergency disaster drill took place on 11/30/2025. At 12:34 p.m., the LPA conducted a review of medication and medication documentation with Co-Administrator, Johnna Udden for three (3) residents. Medications are located in locked cabinets adjacent to the kitchen and living room. At 1:01 p.m., the LPA, along with Co-Administrator, Johnna Udden toured the physical plant areas inside and outside to ensure there are no health and safety hazards. KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:01 p.m., hot water measured at 110.1-degree Fahrenheit. Continued on LIC-809-C. BEDROOMS: The facility is a single-story residential home with five (5) bedrooms, four (4) for resident use and one (1) staff room and three (3) bathrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside the temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid materials. Hot water measured within required range, between 105.3- and 107.4-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. OUTDOOR SPACE: At 1:05 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There are two (2) self latching gates on the sides of the house designated for an emergency exit. The garage is attached and remains inaccessible to residents. Laundry units are located inside the garage. Cleaning solutions are located inside the garage. Additional food supplies and water are also stored in the garage. There are no bodies of water on the premises. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. At 11:10 a.m., the LPA observed the residents and staff participating in a live music activity. The LPA observed the fire extinguisher to be fully charged and last serviced on 10/06/2025. At 1:10 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallways and passages. All exits have functioning auditory devices and were operational at the time of the visit. There is a working telephone on premises. The LPA observed additional clean linens and towels in the hallway cabinets. The fireplace was adequately screened at the time of the visit. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.