Routine inspection·September 23, 2025

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Susan Ponce, Wellness Director and explained the purpose of the visit. The facility is a Continuing Care Retirement Community (CCRC) that consists of Independent Living, Assisted Living, and Memory/Dementia Care. The facility is licensed for a capacity of 547 residents of which there can be 82 non-ambulatory in Independent Living, 29 non-ambulatory in Assisted Living; and 18 non-abulatory residents in Memory/Dementia care. Currently there are 16 residents residing in Memory Care; 27 residents residing in Assisted Living; and 315 residents residing in Independent Living. There are 5 residents currently on hospice. Entrance interview conducted. LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings throughout the facility were checked. The facility was seen to be in good repair inside and outside. LPA observed two fire extinguishers last serviced on 6/26/2025, one fire extinguisher last serviced on 6/3/2025, and four fire extinguishers last serviced on 5/19/2025. There is a fire pull alarm system with pull alarms throughout the facility. The pull alarms ring directly at the local fire department. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Residents participate independently in holiday and birthday celebrations, current event discussions, live entertainment, physical exercise and activities, and outings to parks, restaurants, museums, theaters, sports activities, and other local attractions. Please continue to 809-C, Pg 2. Entrance into the facility is through the Administration building where several offices are located including Executive Director, Wellness Director, Human Resources, Finance, and Chaplain. The Independent Living area is approximately 60 acres with approximately 250 cottages throughout the campus. The Assisted Living area has 26 apartments located adjacent with 17 memory care apartments within the building. There are walkways throughout the residential areas with close proximity to the dining area, salon, a campus store and recreation area. Residents’ apartments have outdoor patios and private bathrooms. LPA observed bathrooms with non-skid flooring and secure grab bars. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs). All persons associated with the facility have criminal record clearance. Administrator certificate is valid. Staff files reviewed had criminal record statements, health screenings, current first aid certificates, and all required training. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.