Taking the Journey North

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator Kelly Eriksen arrived later. Facility has residents with a dementia diagnosis and two residents on hospice, which are within their approved hospice waiver. LPA/staff toured the building and grounds and observed the following: The facility was clean and at a comfortable temperature. No obstructions were observed at passageways. The facility has at least two day supply of perishable and seven 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 furnished per regulation. 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 109.6, 113.3 and 112.1 degrees F, within the allowable range of 105 to 120 degrees F. Fire extinguishers were observed to be charged as of 1/2026. 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 10/30/2025. Facility has a backup generator for use during a power outage. Medication is centrally stored in a locked closet in the hallway. Emergency go bags were observed. Required postings were observed. Annual fees are current. Continued on LIC809C... Continued from LIC809... At approximately 9:30 am LPA initiated file review of five residents and four staff files. Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. All staff have current CPR/1st aid certificates and training hours completed. Kelly Eriksen Administrator Certificate 7008387740 expires 11/4/2027. A spot check of medications was conducted and no discrepancies were observed. Administrator agreed to submit updates of the following not later than 2/19/26: Personnel Report (LIC500), copy of liability insurance, Administrative Organization (LIC309). No deficiencies cited during today's visit. Exit interview conducted with Administrator and copy of report was given.the state’s words, verbatim · CDSS document, Feb 5, 2026

Type of visit: Required - 1 Year

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 & 1st 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 Insurancethe state’s words, verbatim · CDSS document, Feb 6, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator Kelly Eriksen arrived later. Facility currently has two [2] residents on hospice which is allowable per the facility's Hospice Waiver for two [2]. One resident is bedridden and resides in bedroom with bedridden fire clearance per STD850. At approximately 9:30am LPA and Admin 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. Kitchen cabinet containing cleaning supplies and sharp knives was locked. 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 bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 112 and 110.5 degrees F, respectively which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 1/29/2024. 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 1/12/2024. Facility has a backup generator for use during a power outage. At approximately 11:35am LPA conducted a review of six [6] out of six [6] resident files. All required documents present. Continued on 809C... Continued from 809... At approximately 1:15pm LPA conducted a review of five [5] out of five [5] staff files. Two [2] out of five [5] staff members did not have the required number of hours completed. Staff (S1) and (S2) are in their first year of employment and have completed 16 hours of training. Per Health and Safety Code 1569.625 - Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required... (deficiency cited, see 809). At approximately 2:30pm 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 6027539740 expired 11/4/2023; however, Admin provided proof of Admin cert renewal docs submitted 1/19/2024. All fees are current as of this time. LPA and Admin discussed facility's Infection Control Plan and Emergency Disaster plan. Licensee will send copy of updated Emergency Disaster plan to CCL within 30 days. No updates made to Infection Control Plan. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Emergency Disaster Plan Evidence of Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 31, 2024

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Post-Licensing Inspection and was welcomed by staff Nancy Cuevas. Staff contacted Administrator Kelly Eriksen who arrived during inspection. There are 6 residents with 2 residents currently on Hospice. Facility tour/inspection began at 8:40 AM: LPA toured the facility on 9/28/2023; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 12/07/2022. Smoke detectors and Carbon monoxide detectors were tested and found to be operational. Hot water temperature measured between 112.4 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. The facility has special care plan of operation and programming for residents with dementia. 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. Toxins are stored in locked laundry room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms at the facility were supplied with paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. File Review began at 10:45 AM: A sample review of six residents & 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. Continue LIC 809-C As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions; although new staff from sister facility (with background clearance & exemption), facility has had delay with guardian response (contacts provided). In addition, Direct care staff have received the additional training requirements; LPA was also provided required proof of CPR & 1st Aid certification. Medication Audit began at 1:20 PM: Medications were centrally stored in locked front 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 are conducted quarterly and in different shifts with the last one being conducted on 9/15/2023. In addition, Kelly Eriksen, Administrator Certificate # 6027539740 expires 11/4/2023. LPA found residents to be clean and comfortable. Rooms for residents were clean and well-organized and furnished as per Title 22 guidelines. The back porch of the house is shaded and provides a safe and secure area for residents to spend time outside. No deficiencies were found at the time of inspection. No citations issued.the state’s words, verbatim · CDSS document, Sep 28, 2023

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.