Routine inspection·February 24, 2026

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Alexandra Holm. House Manager, Meredith Pritchard-Malo arrived during the visit. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. 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 resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 119 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. Review of resident records indicated R#6 did not have TB test results on file. The infection control plan was not readily available at the facility. Staff confirmed the plan was completed. However, they have not been trained on the infection control plan. The facility did not have training on file for their Emergency Disaster Plan. No deficiencies were observed or cited during today's annual inspection. However, Advisory Notes were issued. An exit interview was conducted with House Manager, Meredith Pritchard-Malo to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. LPA was away from the facility for approximately one hour between 1:30pm and 2:30pm.