Routine inspection·January 29, 2026

On 01/29/26, 10:00 am, Licensing Program Analysts, (LPAs) Raymond Comer and Nicholas Reed, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Facility Administrator, and reason for the visit was disclosed. Facility is licensed as a two story building. Fire clearance approved for sixty (60) non-ambulatory, and sixty (60) ambulatory, for total capacity of one hundred and twenty (120) residents. Hospice waiver approved for ten (10). Currently, the facility is has no residents due to major infrastructure repairs that were recently completed in late 2025. Per Administrator, resident admissions are estimated to commence by May, 2026 . At 10: 20 am, LPAs conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 72.0°F. , within the required range. Facility maintains an approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire extinguishers were observed on all floors of the facility; last serviced on May 2025 . Evacuation chairs were observed atop the facility's two (2) stairwells. Roof access is inaccessible to residents. Evacuation routes are labelled and prominently posted. [LIC 809-C]-Continued Kitchen: At 10: 45 AM, LPA observed kitchen appliances and fixtures as functional . Sufficient amounts of non-perishable food observed at the facility. Perishable food items are not required at this time as there are no residents. Knives and sharps are inaccessible to residents. Medications: Medication room is located on first floor, directly across from rooms #118 and #119; room is securely locked and will be inaccessible to residents. Laundry: LPA observed the laundry room, located on the first floor by the kitchen area; room observed as clean and clear of obstruction. Laundry room is securely locked and will be inaccessible to residents. Commons: First floor maintains one (1) dining room, and (1) activity room. Second floor maintains two (2) activity rooms and one (1) theater room. Common areas observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Bedrooms: LPA observed random resident bedrooms (#115, #116, #120, #209, #211, #214) and bathrooms for safety, privacy, and comfort. Rooms were inspected and observed to maintain required furnishing and sufficient lighting, bed linens, and blankets. Bedrooms were observed to be clean and clear from obstruction. Bathrooms were observed as clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip surfacing). Water temp measured between 103°F. and 108.0°F; Within required range. Outdoor patio area observed to be shaded, with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. Resident records: Records room is located on the first floor, which is locked and inaccessible. There are no residents records, as facility is currently non-operational. Staff records: Records room is located on the first floor, which is locked and inaccessible. A total of three (3) staff files were reviewed. Criminal record clearances were present and Staff are associated to this facility. Staff records appear to be complete and current. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was provided.