Taking the Journey

Type of visit: Required - 1 Year

On 07/06/2026 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by House Manager, Elia Cuevas. Licensee Kelly Ericksen arrived shortly after. Facility has an approved fire clearance and capacity for six (6) Non-Ambulatory, of which one (1) may be bedridden. The facility currently approved hospice waiver for capacity of four (4) individuals. Upon arrival, LPA was informed that there were six (6) residents in care and two (2) staff members on-site. Facility is a 1 story building with five (5) Resident bedrooms, 2 bathrooms, and common spaces. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:25AM, LPA and House manager toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of preparing lunch and cleaning up kitchen at the time of this inspection. LPA observed trash bins did not have cover or lid (Technical Advise Given). Toxins are stored in a under the kitchen sink and in the laundry room. Water temperature measured 109.2 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 01/28/2026 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet closet in the living room. Continued on LIC809-C... Continued from LIC809… LPA reviewed three (3) resident records and found all residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contained physician's orders for each resident. LPA also reviewed four (4) staff records. All records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1st Aid certification. Administrator Certificate for Kelly Ericksen #7008387740 expires on 11/04/2027. The LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 05/04/2026. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 07/16/2026: -LIC 308 Designation of Facility Responsibilities -LIC 500 Personnel Summary -LIC 610 Emergency Disaster Plan (Last page) -LIC 9020 Register of Facility Client’s/Resident’s -Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 6, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

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 & 1st 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 Insurancethe state’s words, verbatim · CDSS document, Jul 15, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection of facility and met with Kelly Eiksen, Licensee. The purpose of this case management is to follow up on updated fire clearance. There are five residents currently. Licensee added a room to facility, submitted permits and fire clearance on 9/13/2024. LPA observed the new resident room, which appears to be in compliance with regulations. No deficiencies cited during today's inspection. Exit interview conducted with Licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 1, 2024

Type of visit: Required - 1 Year

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 & 1st 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 Insurancethe state’s words, verbatim · CDSS document, Jun 4, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.