Facility Evaluation Report

On July 15, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Executive Director, Janna O'Sullivan and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 4 story facility; Assisted Living (AL) on the first and second floor and Memory Care (MC) on the third and fourth floor. LPA toured the facility including but not limited to a random sample of resident rooms on each floor, common areas, and kitchen area. LPA observed some residents doing activities with staff or walking around at the facility. A comfortable temperature of 74 degrees is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured between 107-113 degrees F throughout the facility. Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars and built-in non-skid mats in each bathroom.

LPA toured kitchen and observed 2 days for perishables and and 7 days non-perishable. Medications, sharps and chemicals were locked and inaccessible to residents. Emergency drill are being conducted and logged every 3 months. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of January 2025. First aid kits were observed present and complete.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No citations are issued during the visit. Report is reviewed with the administrator and a copy is provided.