Most inspections found no deficiencies, with the facility generally maintaining clean, safe, and well-managed conditions. Several complaint investigations were unsubstantiated, including allegations about safeguarding personal items and illegal eviction. The most recent report from July 10, 2025, cited one minor deficiency related to water temperature in a resident’s bathroom sink, which was corrected during the inspection. No fines, enforcement actions, or severe issues were noted in the available reports. The facility’s record shows consistent compliance with only isolated, minor issues and no clear pattern of worsening or recurring problems.
The inspection was a required annual unannounced inspection conducted by the Licensing Program Analyst to assess compliance with licensing requirements.
Findings
The facility was generally clean, odor and pest free, with required furniture and adequate food supply. One deficiency was cited related to water temperature in a resident's bathroom sink exceeding the allowed maximum, which was corrected during the inspection.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Water temperature in a resident's bathroom sink measured 124 degrees Fahrenheit, exceeding the allowed maximum of 120 degrees, posing an immediate health and safety risk.
Type A
Report Facts
Capacity: 110Census: 88Water temperature: 124Fire safety service date: Jun 18, 2025Elevator service date: Nov 25, 2024Food supply duration: 2Food supply duration: 7Resident files reviewed: 7Client files reviewed: 9
Employees Mentioned
Name
Title
Context
Ellen Lindstrom
Licensing Program Analyst
Conducted the inspection and authored the report
Larry Potter
Designated Facility Administrator
Facility administrator met with the Licensing Program Analyst and corrected the deficiency during the inspection
The visit was an unannounced complaint investigation conducted in response to an allegation that staff were not safeguarding resident personal items.
Findings
The investigation found that the facility has a laundry policy to keep resident clothing separate and accounted for, and interviews with staff, residents, and a resident's responsible party confirmed the policy is followed. The allegation was determined to be unfounded due to consistent information and evidence that personal items were safeguarded.
Complaint Details
The complaint alleged that staff were not safeguarding resident personal items. The investigation included interviews with staff, residents, and a resident's responsible party, as well as a review of a resident file. The allegation was found to be unfounded.
Report Facts
Capacity: 110Census: 93
Employees Mentioned
Name
Title
Context
Larry Potter
Executive Director
Met with Licensing Program Analyst and involved in investigation
Maja Jensen
Licensing Program Analyst
Conducted the complaint investigation
Christine Mancuso
Business Office Manager
Met with Licensing Program Analyst and involved in investigation
The inspection was an unannounced required 1 year annual visit conducted by Licensing Program Analysts to assess compliance with regulatory standards.
Findings
The facility was found to be in substantial compliance with no deficiencies noted. The grounds and physical plant were well maintained and sanitary, safety equipment was in compliance, and resident care and staff files were complete and satisfactory.
Report Facts
Number of activities scheduled: 7Number of staff files reviewed: 10Number of resident files reviewed: 10Number of residents interviewed: 5Number of staff interviewed: 5Food supply duration (perishable): 2Food supply duration (non-perishable): 7
Employees Mentioned
Name
Title
Context
Larry Potter
Executive Director
Met with Licensing Program Analysts during inspection
The inspection was a Case Management - Annual Continuation visit to evaluate compliance with regulations and facility operations.
Findings
The inspection found all medications, documentation, common areas, resident rooms, and exterior areas to be in compliance with no deficiencies cited. Technical Assistance was offered but no deficiencies were observed.
Report Facts
Window screens needing repair: 12
Employees Mentioned
Name
Title
Context
Larry Potter
Administrator
Met with during inspection and mentioned in exit interview
The inspection was an unannounced annual inspection conducted by the Licensing Program Analyst Kimberly Viarella to evaluate the facility's compliance with licensing requirements.
Findings
The facility was inspected for compliance including a tour of the kitchen where food safety measures were reviewed. The fire extinguisher and hood inspections were up to date, food supplies were adequate, and opened packages were dated. One noted issue was a storage container of Thick It without an expiration date, which was corrected by adding an expiration date after contacting the manufacturer.
Report Facts
Hospice waiver residents: 10
Employees Mentioned
Name
Title
Context
Larry Potter
Designated Facility Administrator
Met with Licensing Program Analyst during inspection and named in report
Stephanie Judd
Director of Wellness
Met with Licensing Program Analyst during inspection and named in report
The inspection was an unannounced complaint investigation visit conducted to investigate an allegation of illegal eviction at the facility.
Findings
The complaint was found to be unfounded after investigation, with no deficiencies observed or cited during the visit. The facility had served a proper 30-day notice to the resident regarding past due fees, and the allegation was dismissed.
Complaint Details
The complaint alleged illegal eviction. The investigation found the complaint to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.
Report Facts
Past due basic service fees amount: 15230Capacity: 110Census: 90
Employees Mentioned
Name
Title
Context
Larry Potter
Administrator
Facility designated Administrator met during the investigation and signed the 30-day notice
Charlie Yang
Licensing Program Analyst
Conducted the complaint investigation visit
Kimberly Viarella
Licensing Program Analyst
Assisted in conducting the complaint investigation visit
Liza King
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
An unannounced case management visit was conducted to review and discuss incident reports sent to Community Care Licensing dating back to January 2023.
Findings
Three resident files were reviewed focusing on physicians' reports, appraisals, and assessments, along with 25 incident reports from February to April 2023. Discussions included potential increase in hospice waiver and annual appraisals of residents.
Licensing Program Analyst Sarah Hurt conducted an unannounced visit for the facility’s annual inspection to evaluate compliance with regulations.
Findings
The facility was found to be in good condition with clean and well-maintained areas, adequate food supply, operational safety equipment, and proper staff COVID vaccination documentation. No deficiencies were observed or cited during the inspection.
Report Facts
Residents on hospice: 10
Employees Mentioned
Name
Title
Context
Stephanie Judd
Director of Health Services
Met with Licensing Program Analyst during inspection and participated in exit interview
Larry Potter
Administrator
Facility administrator with certification expiring 06/29/2023
The inspection was a required unannounced 1-year visit to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to be operating within the scope of its license with no deficiencies identified. All resident and staff files reviewed were in compliance, and safety equipment and environmental conditions met requirements.
Report Facts
Residents on hospice: 5Fire extinguisher expiration date: Jan 25, 2022Water temperature: 111Resident files reviewed: 5Staff files reviewed: 5
Employees Mentioned
Name
Title
Context
Larry Potter
Administrator
Met with Licensing Program Analysts during inspection
The visit was a case management contact conducted via telephone due to COVID-19 precautionary measures, following receipt of an Unusual Incident/Injury Report regarding a resident's fall and subsequent death.
Findings
The report documents that a resident on hospice had an unwitnessed fall resulting in injuries and hospitalization, and subsequently passed away. The facility provided information and a copy of the report via email due to COVID-19 precautions.
Report Facts
Census: 90Total Capacity: 110
Employees Mentioned
Name
Title
Context
Jason Lund
Licensing Program Analyst
Conducted the case management contact and discussed the purpose of the call
Alexis Alvarez
Assisted Living Manager
Facility representative met during the visit and exit interview
Stephenie Doub
Licensing Program Manager
Named in the report header
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