Routine inspection·March 5, 2026

Licensing Program Analysts (LPAs) Quoc Huynh and Trevor Byrne arrived at the facility unannounced to conduct the required annual visit beginning at 11:18 AM. LPAs met with facility Executive Director (ED) Grace Hartnett. Entrance interview conducted and the reason for the visit was explained. The facility has three (3) floors divided into separate areas of memory care, assisted living, and independent living occupants. The facility is licensed in Building A on the 1st, 2nd and 3rd floor and In Building B, only on the 2nd floor as an RCFE. Beginning at approximately 12:30 PM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS : There are One-Hundred sixty-three (163) bedrooms in the facility, one-hundred and forty one (141) are assisted living bedrooms and twenty two (22) are memory care bedrooms. LPA and the facility Administrator toured sixteen (16) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA tested the emergency pull cords in two (2) resident rooms. The staff's response time did not exceed six (6) minutes. BATHROOMS : All resident bedrooms in the facility have attached private bathrooms and shared bathrooms are located throughout the common areas of the facility. All bathrooms LPA inspected were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 106.0 and 113.7 degrees Fahrenheit, which is in compliance with regulation. Continued on LIC 809C. KITCHEN/DINING ROOM : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed the kitchen to contain adequate emergency food supplies. LPA observed the kitchen entrance to be under staff observation. LPA observed the dining room to be clean and properly furnished at the time of the visit. The dining room contained adequate seating and tables for resident use. COMMON AREAS : LPA observed cameras to be located throughout the facility’s hallways. LPA observed the facility’s activities room, libraries, theater, salon, art gallery, and gym. All common area rooms were observed to be clean and in good repair. All furniture observed was in adequate condition and was free from rips and tears. LPA observed locked janitorial closets and laundry rooms throughout the facility’s hallways. The facility had adequate indoor space to accommodate resident’s activities. LPA observed the entryway of the facility to contain two (2) properly screened fireplaces. LPA observed fire extinguishers located throughout the facility to be last serviced on 08/18/2025. LPA observed the facility’s fire alarms, fire doors, emergency power generator, elevators, and sprinkler system to be certified through 10/31/2027 and 05/31/2028. LPA observed the stairwells of the facility to be clear and all stairwells were observed to contain evacuation chairs. OUTDOOR SPACE: LPA observed the outdoor spaces of the facility. LPA observed two (2) terraces and one (1) outdoor yard. LPA observed the outdoor yard to contain an appropriately fenced off pool, a greenhouse, and planter boxes utilized for resident activities. LPA observed clear passageways for emergency exit use. MEDICATION REVIEW: Medication review began at 03:56 PM. Medications are stored centrally and securely in two (2) medication rooms located in each wing of the facility. LPAs observed medications for five (5) residents. All medications were observed to be documented appropriately on their respective centrally stored medication and destruction record sheets. INTERVIEWS: LPAs interviewed five (5) residents and six (6) staff members. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. All staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. Continued on LIC 809C. RECORD REVIEW: Record review began at 12:47 PM. Staff and resident records were reviewed for documents including, but not limited to: TB test, physician's report, needs and service appraisal, consent forms, admission agreements, and personal rights. Ten (10) resident files were reviewed. All resident files contained all required documentation and signatures. Ten (10) staff files were reviewed. All staff files contained all required documentation and trainings. No deficiencies were observed during record review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The facility’s emergency disaster plan is up to date and is adequate. Disaster drills are conducted quarterly and the facility's last emergency disaster drill was conducted on 02/13/2026. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. During today’s visit LPAs obtained a copy of the facility’s emergency disaster plan, resident roster, LIC 500. Administrator agreed to email LPA a copy of the liability insurance no later than end of day 03/06/2026. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.