Inspector’s narrative
What the inspector wrote
On 10/23/25, Licensing Program Analysts (LPA) Regina Cloyd and Socorro Leandro conducted an unannounced required – annual inspection and
met with Executive Director Keith McGevna
. The facility is licensed to serve 286 ambulatory residents age range 60 and over, of which 98 may be non-ambulatory and of which 28 may be bedridden. Hospice waiver granted for 20 residents. The facility currently has two residents receiving hospice care. Annual Fees are current.
The facility consists of floors 1 – 6 and basement. The first floor consists of 24 resident rooms, salon spa, massage, event center, theatre, occupational physical therapy, card rooms, library, grab & go, bar lounge, dining room, living room, private dining, kitchen, memory, two outdoor dining courtyards, and memory care courtyard. The second floor consists of 42 resident rooms and a garden terrace. The third floor consists of 38 resident rooms. The fourth floor consists of 38 resident rooms. The fifth floor consists of 38 resident rooms. The sixth floor consists of 19 resident rooms, wellness center, fitness center, spa, locker rooms, sun deck, and enclosed pool.
Continue to LIC809-C.
Staff accompanied LPA Leandro inside and outside the facility during this inspection.
Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards. Doorways were free of obstructions. Resident bedrooms (1-06, 110, 2-9, 2-11 303, 322, 327, 422, 441, 531, 604 and 627) had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, a non-skid mat was in place, and hot water temperature properly measured between 114 – 117 degree Fahrenheit. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.
LPA Leandro toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives were kept in the locked kitchen area.
First Aid kit was available. Fire Masters tested the exits and fire extinguishers on 06/17/25. Johnson Controls North America conducted its fire inspection on 06/06/25 and the automatic sprinkler systems on 10/08/25.
The facility conducted an emergency drill (safety & risk management) occurred on 09/17/25.
Ten staff records were reviewed, ten out of ten staff records had required criminal record clearances or criminal record exemptions.
Ten resident records were reviewed, ten out of ten resident records had medical assessments and/or annual routine visits, pre-appraisal, and reappraisals. Both medication rooms were inspected and electronic medication administration records reviewed.
An exit interview was conducted, technical assistance provide, and a copy of this report was discussed and left with
Executive Director Keith McGevna.
