Routine inspection·July 31, 2025

Licensing Program Analyst (LPA) Arian Golbakhsh and Licensing Program Manager (LPM) Sabel Martinez conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA and LPM were welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Stephanie Boudreau. The facility's license shows a maximum capacity of 783 non-ambulatory residents. Additionally, the facility is approved for 25 hospice waivers. During today’s inspection there were 523 residents in care. LPA, LPM, and ED Boudreau toured the interior and exterior of the main floor and inspected common areas as well as a sample of resident units in the South Tower. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms inspected 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: Kitchen sink in a unit on the 20th floor read at 108.3F.. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. 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. Knives were stored in areas inaccessible to residents. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Centrally stored medication for the Independent Living Residents were labeled, as required, and stored in locked areas. An indoor pool exists on the premises. LPA and LPM observed the pool to have three (3) secured entryways with electronic key access. Per ED Boudreau, only eligible residents who have been assessed may have access to the pool. Per ED Boudreau, no firearms or ammunition are kept at the facility. Fire extinguishers were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. LPA and LPM interviewed 2 staff and 3 clients, and interviews did not reveal any licensing or regulatory concerns. Due to time constraints, an additional visit on a subsequent date is required to complete the annual inspection. No deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Boudreau to whom a copy of this report was provided. Their signature below confirms receipt of this document.