Facility Evaluation Report

On 12/06/2024 at 11:00 AM, Licensing Program Analysts (LPAs) James Sampair and David Doidge arrived unannounced to conduct this 1-Year Annual Required inspection. The LPAs explained the purpose of the visit and met with Assistant Executive Director (AED) Iryn Macamay.

The LPAs toured rooms of the facility, which included but not limited to bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. The LPAs observed that the lighting in all of the rooms is adequate for the comfort and safety of the residents. The room temperature measured in Room 217 was 70.7 degrees Fahrenheit. The hot water temperature is monitored daily by maintenance staff and measured between 114 and 119 degrees Fahrenheit over the past week.

There is a minimum of one week supply of nonperishable and 2 days of perishable foods. Centrally stored medications, sharps are locked, and inaccessible to residents in care. The first aid kit was observed to be complete. The pool was appropriately fenced and secured. The fire extinguishers were last serviced on 12/13/2024. The emergency disaster plan is reviewed at least annually, and the last update to the plan was made on 12/4/2025. Emergency disaster drills are conducted monthly and last conducted on 11/27/2025.

The LPAs reviewed five (5) resident records and five (5) staff records, all were complete.

No deficiencies observed or cited during this visit.

Exit interview conducted and a copy of this report provided