Routine inspection·October 9, 2025

On 10/09/25, 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced inspection of the Facility. LPA met with Resident Care Director, Nathaniel Akyempon, and reason for the visit was disclosed. Administrator's Certificate is valid; expiration date: 10/05/2026. Facility is licensed as a four story complex, maintaining resident bedrooms with private bathrooms, and multiple public bathrooms. Fire clearance approved for (125) non-ambulatory, and an additional twenty-five (25) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, no residents were receiving hospice care services, and no bedridden residents. At 10:25 am, LPA toured the physical plant and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main doors are the primary entry/exit point, including four (4) emergency exits: Two exits off the northeast and northwest corners of the facility, one exit off the south corner, and one exit off the southeast corner. Screening area is located immediately upon entrance. Visitor sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Facility is separated into Independent/Assisted Living, (second, third, fourth floors) and Memory Care. (First Floor) As the Facility provides dementia care, LPA observed the delayed egress system working properly. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F., within the required range. Required postings are prominently displayed and observed as current. [Continued on LIC 809-C] FIRE SAFETY: Fire detection system is present in the facility. LPA observed multiple smoke and carbon monoxide alarms installed, hardwired, and interconnected. Fire system monitoring is serviced on a monthly basis. Fire alarm system was tested and working properly. Fire drill was last conducted in Sept, 2025. Fire extinguishers were observed on all floors of the Facility. All extinguishers were last serviced on 2/19/2025. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. LPA observed evacuation chairs in facility stairwells. KITCHEN: At 11:10 am, LPA observed kitchen to be clean, with an adequate supply of perishable and non-perishable foods located in the refrigerator, freezer, and pantry. LPA observed a variety of fresh fruits, vegetables, meats, dry cereals, and desserts. Foods are properly labeled and stored. Knives and sharps are stored in a designated area of the kitchen and inaccessible to residents. LAUNDRY: LPA observed laundry rooms located all floors for residents to launder their personal clothing; with the exception of the first-floor Memory Care Unit. Laundry areas were clean and clear from obstruction. Facility bed linens, towels, etc. are serviced by contracted laundering vendor. BEDROOMS: LPA conducted random observations of resident bedrooms (#105, #222, #234, #305, #319, #321, #412, #414, #416) for safety, privacy, and comfort. Bedrooms were inspected and observed to maintain required furnishings and sufficient lighting, bed linens, and blankets. All observed bedrooms were clean, free of odor, and clear of obstruction. B ATHROOMS: were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured between 108.0°F. and 116.0°F.; within the required range. COMMONS: LPA inspected activity rooms, movie theater, salon, wellness centers, gym, library, dining rooms, and reception areas. Common areas were observed to be clean with adequate furnishings for resident use. Furnishings are in good condition. No obstructions, nor tripping hazards observed. Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report was provided.