Facility Evaluation Report

On 7/16/2025 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with General Manager, Michael Fillari and Health & Wellness Director, Susan Donaghy. LPA explained the reason for the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 3/5/2025. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies twice a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 32 degrees F. Hot water temperature was measured at 113.9 degrees F in a resident's bathroom sink. Grab bars and non-skid mats were observed. There were adequate lights in each room. The facility has a written emergency disaster plan. Last fire drill was conducted on 6/2/2025. LPA observed stairwells have evacuation chairs.

LPA reviewed 5 residents and 5 staff files starting at 10:30AM. All staff are fingerprint cleared and associated to the facility. LPA reviewed a sample of resident's medications during inspection.

No deficiencies are being cited on this date.

Exit interview conducted with Susan. A copy of this report provided.