Routine inspection (multi-day)·November 6, 2025

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conclude the required annual licensing inspection that commenced on October 30, 2025. LPA was met by Administrator Derafora, identified herself, was granted entry into the facility, and stated the purpose of today’s visit. During today's visit LPA conducted a review of facility, staff, and resident records that were complete and up to date. Staff training, disaster drills, administrator certification, liability insurance, and required licensing forms were present and current and/or active. Additionally, a review of resident medication administration records was accurate and complete. The facility is equipped with Personal Protective Equipment (PPE) and a first aid kit and manual. LPA Correia, accompanied by Administrator Derafora, conducted a tour of the remaining portion of the interior of the facility, and a toured the exterior of the facility. The taps at faucets used by residents measured within compliance. The facility pool is surrounded by a locked gate and is inaccessible to residents in care. There is a shaded area for outside activities, and no obstructions or trip hazards were observed. Based on today's visit, there were no deficiencies observed at this time in the areas evaluated. An exit interview was conducted with Administrator Derafora who will be provided with a copy of this report and license/appeal rights (LIC 9058 01/16), and their signature on this form acknowledges receipt of these documents. During today's visit LPA left for 2.5 hours to conduct additional Licensing business and take a lunch break.