Facility Evaluation Report

On 9/10/25,L icensing Program Analyst (LPA) Kevin Mknelly arrived unannounced at the facility to conduct a required annual inspection utilizing the full CARE tool. LPA met with Executive Director, Michael Clymo, and explained the purpose of the visit.

During today's inspection, LPAs and Executive Director conducted a tour the interior and exterior of the facility. Areas toured included but not limited to: courtyard, memory care unit bedrooms, assisted living unit bedrooms, main dining, kitchen, gym, and the common areas. LPAs observed care staff assisting residents with walking and other activities. LPAs observed the facility to be clean, safe and in good repair.

File review was conducted for 6 residents and 2 personnel files. LPAs observed the files to be mostly complete with the required documents. Inspection tool completed and found staff training documentation to not contain required training for some staff.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Michael Clymo . Copy of this report and appeal rights provided.