Routine inspection·April 28, 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 concierge CJ Isidro, who allowed LPA entry. LPA then met with Executive Director Jeremy Danenhauer and Assistant Resident Services Director Agnes Tuazon. Note, LPA did step out for lunch from 12:30-1:30pm. The facility's license shows a maximum capacity of one-hundred-and-twenty-five (125) non-ambulatory residents, thirty-nine (39) of which may be bedridden. Per the fire clearance, all bedrooms are approved for bedridden occupancy. Additionally, the facility is approved for a hospice waiver for twenty-five (25) and delayed egress in the Memory Care unit. During today’s inspection there were one-hundred-and-four (104) residents in care, with thirteen (13) currently on hospice. LPA and Executive Director Danenhauer toured the interior and exterior of the facility and inspected common areas and a sampling of occupied and unoccupied resident rooms. Director of Mental Health Care David Kraft joined for the tour of the Memory Care unit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. [Continued on LIC 809-C] [Continued from LIC 809] LPA tested hot water temperatures at taps accessible to clients. A bathroom sink in a resident's unit on the 3rd floor read at 124.9F and another 3rd floor unit tested at 124.3F. LPA additionally tested a sink on the first floor which read at 122F. Maintenance staff went to adjust the water heater and LPA tested the water again and third floor read at 108.7F. One Type A deficiency was issued for the hot water being above the approved range of 105F to 120F. The facility does maintain daily water temperature logs and in the week leading up to today, recorded temperatures routinely ranged from 114-116F. 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 the main kitchen which is occupied by staff during the day (kitchen locked at night). The kitchen maintained a system to track resident modified diets and allergies. No toxic chemicals or poisons were accessible to clients at risk if given access to such items.  Medications were labeled, as required, and stored in locked areas. No pools or large bodies of water exist on the premises, however, the Assisted living area courtyards have two (2) water fountains. Per Executive Director Danenhauer, residents who are at risk to be near the fountains do not reside in the Assisted Living community, but just in case, residents are generally not alone when in the courtyard. Per Executive Director Danenhauer, 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 extinguishers of the Assisted Living areas were serviced within the last 12 months, dated for last week. LPA noted that the fire extinguishers in the Memory Care unit hadn't been serviced yet but still within a year for servicing, and it was discovered the servicing company had skipped over the unit. Maintenance was able to contact the company and schedule a return date to complete the extinguisher servicing. [Continued on LIC 809-C] [Continued from LIC 809-C] First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility and LPA noted copies of licensing and Ombudsman contact posters were present on each floor. LPA observed resident's engaged in a variety of group and individual activities throughout the facility. LPA also observed staff tending to residents timely and with respect. LPA interviewed two (2) staff and two (1) client, and interviews did not reveal any additional licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents, however as LPA reviewed staff records, LPA noted that one staff member did not have a health screening and TB test on file, and another had a health screening but no TB test. One Type B deficiency was issued for the missing health screening/TB test for the two (2) staff. Confidential records were stored in locked areas. Maintenance/Disaster records were complete and well organized. Last staff emergency drill was conducted on 4/18/26 for the topic of mattress fire. Two (2) deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Danenhauer to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.