Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Residential Health Services Manager (RHSM) Alison Humora and Operations Manager (OM) David Sharp. Executive Director (ED) Kristen Kearnaghan arrived later during the visit. The facility's license shows a maximum capacity of one-thousand-two-hundred-and-thirty-three residents (1,233), all of whom may be non-ambulatory. Additionally, the facility is approved for a hospice waiver for nine (9). During today’s inspection there were eight-hundred-and sixty (860) residents in care, with five (5) currently on hospice.

LPA and ED Kearnaghan toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. Director of Plant Operations Ben French joined for the second half of the walkthrough. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms visited contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, and LPA briefly observed staff in the facility's laundry room. Physical separation of clean and soiled laundry was maintained.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Each building contained at least one common room with plenty of space and seating. Main clubhouse buildings included a variety of activity spaces and activity calendars were readily available in common areas.