Routine inspection·February 24, 2026

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Carl Measer, Assisted Living Director (ALD) Mary Fawell, and Memory Care Director (MCD) David Pinto. The facility's license shows a maximum capacity of seventy-seven (77) non-ambulatory residents, nine (9) of which may be bedridden. Bedridden residents may only reside in building E, rooms #1-9. In addition, the facility is approved for a hospice waiver for twenty (20). During today’s inspection there were sixty-seven (67) residents in care. Currently, the facility has five (5) residents receiving hospice services. Note, LPA did step out for lunch from 12:20-1:20pm. LPA and ALD Fawell toured the interior and exterior of the Assisted Living (AL) building, inspecting common areas and a sample of occupied resident rooms. LPA then toured the interior and exterior of the Memory Care (MC) building with MCD Pinto. Both buildings of the facility were clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: One common bathroom sink in the AL building was 108.8F, and two private resident sinks in the MC building read at 108.2F and 107.7F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. [Continued on LIC 809-C] [Continued from LIC 809] The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Both buildings feature satellite kitchens, and the main kitchen/food storage is on a different area of the campus. LPA examined the kitchens and noted food items in those areas were all safely stored. LPA observed dining staff transporting food items from the main kitchens to the satellite ones to prepare for lunch. Cooking, dining equipment, and utensils were present. Knives were noted to be in areas locked and inaccessible to residents. No toxic chemicals or poisons were accessible to clients. LPA and ALD Fawell spoke briefly on medication administration and best practices. Medications in both buildings were labeled, as required, and stored in locked areas. The outdoor courtyard of the AL building does feature a large koi pond with a water-fountain feature, however it is fenced off. Per ALD Fawell, Memory Care residents or other residents at risk if given access to such bodies of water are accompanied by staff if in the area. There is a small water fountain in the yard of the MC building, however it has been adjusted not to feature standing water, mitigating risk for residents. Per both ALD Fawell and MCD Pinto, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire panel in the MC building was last inspected by the local fire department in January 2026. Fire extinguishers were serviced within the last 12 months, also dated for January 2026. Last staff emergency drill was conducted on 12/20/25 and 12/24/25 (different shifts) for the topic of fire. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility, however in the AL building there was no posting of resident personal rights. Per ALD Fawell, they had been taken down to be reframed due to updates to the building months prior. A Technical Violation (TV) was issued and consultation provided regarding required licensing postings. LPA interviewed one (1) staff and two (2) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with ALD Fawell to whom a copy of this report, LIC 9102 (TV), and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.