Pre-licensing visit·March 25, 2026

Licensing Program Analyst (LPA) Erica Mosley conducted a pre-licensing visit to the above-mentioned facility at 10 AM. LPA met with Belmont Village Executive Director (ED), Mark Ranno, and Belmont Village Director of Resident Care Services, Karen Pasten, along with the applicant / Executive Director (ED) / Regional Director of Operations Jason Malone. This application is for a Change of Ownership Application (CHOW) currently operating with Facility license # 565802433 and the current licensed facility has residents in care. The facility is a four (4) story building that consists of a memory care unit, and an assisted living unit. There are fire sprinklers and fire doors throughout the facility. A physical plant tour was conducted inside and out. An approved fire clearance was received on 02/25/2026, clearing them for a capacity of 158, of which ten (10) may be bedridden, and 148 may be non-ambulatory. All rooms are approved for non-ambulatory and bedridden residents. An updated document of room numbers/locations of all bedridden residents shall be maintained and available to emergency responders upon request. Delayed egress is approved for the memory care unit. Age range 60 and over. Hospice care waiver submitted and is pending approval. Common Areas: The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. There are fire extinguishers throughout the facility that were fully charged and were last serviced 04/04/2025. The LPA observed required postings throughout the common space. The LPA observed the stairwells, and they each had an emergency evacuation chair at the fourth floor. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. LPA observed laundry rooms on all floors. Report Continued on LIC 809C... (PAGE 2) Report Continued from LIC 809... Bedrooms: The LPA observed fifteen (15) randomly selected resident bedrooms, of which five (5) were in memory care and ten (10) in assisted living. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. All rooms had a comfortable room temperature of 75 degrees Fahrenheit. Hot water temperature was measured in all fifteen (15) bathrooms and they were between the temperature range of 105-120 degrees Fahrenheit. Lighting in the rooms appeared adequate. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is a brake room for staff at the facility. For nocturnal (NOC) shift, there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. The resident bathroom(s) have a shower with non-skid materials. The toilets were in working conditions and the showers have grab bars. Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. LPA observed facility generator to function properly at the time of the visit. Kitchen : The LPA inspected the kitchen/food service area the kitchen was observed to be inaccessible to residents in care. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Dining room furniture was observed to be in good condition and appeared to be relatively clean. The supply of dishes, utensils, pots, pans and drink ware is adequate. Refrigerator and food pantry were checked for proper labels and expiration dates. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Trash cans had tight fitting lids. No flies or other vermin were observed. The LPA observed an adequate supply of emergency food and water. Report Continued on LIC 809C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... Medications: The medications are centrally stored in the wellness room located on the third floor along with a medication cart on the second floor for the memory care unit which remains locked at all times. First aid supplies were complete along with a current version of a first aid manual. Resident and staff files will remain in Administrators offices, locked. Component III was conducted in conjunction with the visit. No corrections required on the pre-licensing visit at this time. Exit interview conducted. Report review and provided electronically. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.