Facility Evaluation Report

At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 Year Required Visit, and met with Resident Care Manager, Sourabh Singh . Executive Director, Mike Sharkey, arrived during visit at approximately 1:00PM. Facility has an approved fire clearance and total capacity of 172 Non-Ambulatory Residents, where 12 can be bedridden. Facility has an approved hospice waiver for 8 individuals. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPA was informed that there were 13 residents in Assisted Living, 15 residents in Memory Care, 3 residents in Extended Care, and 45 Independent Living residents for a total of 76 residents in care. LPA was also informed that there were 22 staff members on-site.

At approximately 9:00AM, LPA reviewed the Facility's Staff Roster with Resident Care Manager and found that all staff members on site were background cleared and associated to the facility per regulation. LPA followed up on an incident report that was self-submitted to Community Care Licensing (CCL).

Incident Report 1/SOC-341: CCL received an incident report and SOC-341 report from the facility on 10/02/2025. Reports stated that on 10/01/2025, Facility's Safely You Video System alerted Staff Member 1 (S1) of Resident 1 (R1) having a fall but they did not check on R1 until 2 hours later. Reports further stated that R1 did not have any injuries due to the fall and S1 was terminated following the incident. Facility made all appropriate notifications per regulation.

LPA obtained documents related to the incident.