Routine inspection·February 11, 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 Residential Health Services Manager (RHSM) Alison Humora and Operations Manager (OM) David Sharp. Executive Director (ED) Kristen Kearnaghan arrived later during the visit. The facility's license shows a maximum capacity of one-thousand-two-hundred-and-thirty-three residents (1,233), all of whom may be non-ambulatory. Additionally, the facility is approved for a hospice waiver for nine (9). During today’s inspection there were eight-hundred-and sixty (860) residents in care, with five (5) currently on hospice. LPA and ED Kearnaghan toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. Director of Plant Operations Ben French joined for the second half of the walkthrough. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms visited contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, and LPA briefly observed staff in the facility's laundry room. Physical separation of clean and soiled laundry was maintained. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Each building contained at least one common room with plenty of space and seating. Main clubhouse buildings included a variety of activity spaces and activity calendars were readily available in common areas. [Continued on LIC 809-C] [Continued from LIC 809] LPA toured the two (2) main kitchens and respective dining areas. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. The kitchens feature automatic alerts for food allergies when a resident places an order for a meal. No toxic chemicals or poisons were accessible to clients.  Medications were labeled, as required, and stored in locked areas. The facility does include two (2) swimming pools, one indoors, and the other outdoors. The outdoor one was fenced and the access gates locked, as required per regulation. The indoor pool access door is unlocked for residents of that building during daytime hours then locked at night. Additionally, the facility grounds feature several water fountain/waterfall fixtures as well as large ponds. Per ED Kearnaghan, Independent Living community residents who may be at risk with access to such bodies of water (such as those with cognitive impairment) are required to have a 24/7 companion and are not left unsupervised. Per ED Kearnaghan, 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 extinguishers were serviced within the last 12 months, dated for December 2025. Last staff emergency drill was conducted on 2/10/26 for the topic of building fire. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed two (2) staff and five (5) clients, and interviews did not reveal any licensing or regulatory concerns. Particular praise was given regarding staff competence and enthusiasm. 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 Executive Director Kearnaghan, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.