Routine inspection (multi-day)·August 14, 2025

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to complete the Annual Inspection partially conducted on July 31, 2025. 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 (ED) Stephanie Boudreau and Associate Executive Director (AED) Amy Patterson. 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 522 residents in care. During today's visit, LPA inspected the North Tower building and Care Center. The areas inspected today were 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. The facility has a water fountain fixture at the front entrance as well as another in front of the dining area at the North Tower. A Deficiency is being cited per Title 22 regulations and noted on the attached LIC 809D. In addition, a Civil Penalty is being assessed for a Zero Tolerance Violation regarding Accessible Bodies of Water and are noted on the attached LIC 421IM in the amount of $500. Additionally, LPA conducted file review. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. Last fire drill conducted with staff was on 7/24/25. One Deficiency was cited during today's visit for the accessible fountains. An exit interview was conducted with Executive Director Boudreau to whom a copy of this report was provided. Their signature below confirms receipt of these documents.