Routine inspection·October 13, 2025

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced annual inspection on 10/13/25 using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Staff, Nancy Mandic, who provided the tour of the facility. The assistant administrator, Meagan Swan, arrived later to assist with the rest of the inspection. The facility is licensed to serve 66 residents, of which (26) may be non-ambulatory and (40) bedridden. There is a hospice waiver approved for (15) residents. The licensed part of the campus consists of (3) cottages called The Hearth, Stewart Cottage, and The Ranch House (Memory Care unit). The Commons building consists of the dining area and kitchen. The liability insurance is maintained at a $1 million for each occurrence and $3 million in total general aggregate. LPA observed the following during the visit today: The Commons building is comprised of a library area, mail room, business offices, dining room, an outdoor dining area, and a commercial kitchen. The food preparation areas were clean. There was adequate supplies of both perishables and nonperishable items. The cleaning supplies are kept in away from the food area. The Hearth building is comprised of resident rooms, activity room, a laundry room, and the medication room. LPA selected (3) rooms (rooms #8, #13, and #15) to inspect. The bathrooms have skid mats, grab bars, and the water temperature was within the required range. Stewart Cottage is comprised of resident rooms, activity room, two family rooms, a shower room, medication room, and a few offices. LPA selected (3) rooms (rooms #4, #7, #12) to inspect. The bathrooms have skid mats and the water temperature was measured within range. The Ranch House (Memory Care unit) is comprised of resident bedrooms, a kitchenette, a library room, a living/dining room area, medication room, and an enclosed outdoor patio. This building has a delayed egress system. The rooms are clean and have sufficient lighting. The hot water was measured within the required range. Each building has a fire sprinkle system installed. Carbon monoxide detectors and fire extinguishers were also observed. The outdoor center area has a pond that is less than 2 ft in depth and is protected with wires. The swimming pool is surrounded by a 5ft fence. LPA selected (7) resident files for review. Each of the files has the admission agreement, consent forms, medical assessment with TB test results, resident's reappraisal plan, and the property valuable form. The medications for these residents were also reviewed and no discrepancies were found. LPA reviewed (5) staff files. Staff have the required documents such as the personnel record, health screening and TB results, first aid training and CPR certificates. Administrator's (Deborah Herbert) certificate expires on 5/2/27. Staff are receiving annual training on dementia care and medication. The Emergency Disaster Plan is reviewed annually and disaster drills are conducted at least monthly for all shifts. No deficiencies were issued today. Exit interview was conducted with Meagan Swan and a copy of this report was provided.