Routine inspection·February 12, 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 Business Office Manager Emerald Jordan and Executive Director Mercedes Margritz. The facility's license shows a maximum capacity of fifty-six (56) non-ambulatory residents. Additionally the facility is approved for a secured perimeter and holds a hospice waiver for twenty (20). There is a separately licensed Adult Day Program on the same property. During today’s inspection there were forty (40) residents in care. LPA and Executive Director Margritz toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. 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. Hot water temperature at taps accessible to clients were all compliant: one common bathroom sink was measured at 106.8F. 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. As the kitchen is locked and requires code access, knives were inaccessible to residents. Kitchenettes accessible to residents throughout the facility did not contain knives or similar sharp objects. [Continued on LIC 809-C] [Continued from LIC 809] While examining the kitchenette in the Pheasant Run area, LPA noted an unlocked cabinet containing cleaning/disinfecting chemicals and sprays. Executive Director Margritz immediately requested Maintenance Director Johnathon Vodicka to come and remove the chemicals to a secured area until locks can be placed on the cabinet. As LPA toured another of the kitchenette areas (English Garden area), LPA observed another unlocked cabinet containing chemical items. This cabinet had a latch, however it was left unlocked. Maintenance Director Vodicka arrived to remove the items, and Executive Director Margritz directed staff to ensure the other kitchenette cabinets were secured or to remove any contents. A Type A violation was cited for the accessible cleaning/chemical items. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Margritz, 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 alarm panel was last inspected March 2025. Fire extinguishers were serviced within the last 12 months, dated for October 2025. Last staff emergency drill conducted was on 2/5/26 for the topic of room fire. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility, however LPA noted there was not a copy of Resident Personal Rights posted inside the residential area of the facility, only a copy posted in the front lobby not accessible to residents. A Technical Violation (TV) was issued and consultation provided on having an accessible copy posted for residents to view. LPA interviewed one (1) staff and zero (0) 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. One deficiency was cited during the inspection. An exit interview was conducted with Executive Director Margritz to whom a copy of this report, the LIC 9102 (TV) and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.