Routine inspection·November 17, 2025

Licensing Program Analysts (LPAs) Edith Conchas and Renese Howell-Small made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Michael Harrison, Executive Director, and discussed the purpose of the visit. The facility is a Continuing Care Retirement Community with independent homes, a two story assisted living unit, and a memory care unit. The facility has a license capacity of (303) residents and a hospice waiver for seven (7) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has sufficient indoor and outdoor space for resident activities. The memory care outdoor activity space is enclosed by perimeter fence gates approved by the Fire Marshall. LPA took a tour of the facility and the resident’s bathrooms were inspected at random and operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 105 to 120 degrees F. The resident’s bedrooms were inspected at random and have sufficient lighting and furniture is in good repair. The facility has operating carbon monoxide alarms, telephone service, laundry equipment and signal system. The facility has sufficient linen, towels, and personal hygiene items for residents. Continued on LIC809-C The facility has posted in resident common areas, The Community Care Licensing complaint posters, Ombudsman posters, facility sketches, and resident monthly activities. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerators and freezers are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas. The facility has posted menus and sufficient dining areas for residents. Care & Supervision : The facility has 24-hour/7 days a week care staff and have in-house drivers to transport the residents. LPA observed several staff assisting with resident care, food service, maintenance and housekeeping . Record Review: The facility conducted a Fire drill on 10/13/2025 and Disaster drill last conducted on 9/26/2025. Emergency Disaster Plan was last updated on 4/23/2025 due to no changes. Facility has a Manual Fire Dampers system last inspected on 11/20/2024 and next inspection due date is on 11/20/2028. The facilities Tamper switch and Water flow device inspection was tested 12/10/2024. Six (6) staff files were reviewed at random and were observed to be complete and included criminal record clearances or exemptions through the Department. Six (6) residents files reviewed at random were observed to be complete. Medical Related Services : All medication was centrally stored and kept locked in the medication room and appeared to be dispensed as prescribed by their physicians. Based on LPA observations and file review, the facility is in compliance with Title 22 regulations and no deficiencies were cited during today's visit. An exit interview was conducted at the conclusion of the visit and a copy of this report was provided to the Executive Director at the conclusion of the visit with appeal rights..