Facility Evaluation Report

On 11/21/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to continue the 1-year required Annual Inspection. LPA Calandra was greeted by Pam Marron, Director of Residential Services and explained the purpose of the visit. Amanda Martinez, Nurse Manager arrived later during the visit.

LPA toured the physical plant. This facility has 30 buildings on the campus(2 of which are memory care and Assisted Living). The facility has a bowling green, spa/pool, putting green, Health Center, Dining room, Skilled Nursing Facility(not licensed by the Department), and Library. LPA inspected random rooms in Memory Care(The Gardens) and Assisted Living(The Lodge). All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed. All bathrooms inspected had slip resistant flooring and grab bars in the showers. Hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility's fire alarms and carbon monoxide detectors were observed to be in working order. The facility's fire extinguishers were observed to be fully charged and last inspected on 4/7/2025. The facility had the required 7 days of non perishables and 2 days of perishables on hand. No food was expired.

All sharp objects, soap, poisons and medications were observed to be locked and in-accessible to persons in care.

LPA received the following documents: Current LIC 500, Administrators Certificates, Emergency Operations Plan

A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

No deficiencies cited during today's visit.

An exit interview was conducted. This report was reviewed with facility representatives and a copy provided.