Most inspections found no deficiencies, with several complaint investigations resulting in unsubstantiated allegations related to medication handling, resident accommodations, food safety, and staff conduct. The facility’s annual inspection on July 24, 2025, cited a minor deficiency for uncovered perishable food items in storage, which posed a potential health risk. A complaint investigation on September 27, 2025, found inaccurate medication record keeping for two residents, leading to a substantiated citation, but no severe issues or enforcement actions were noted. The most recent report from September 27, 2025, showed this medication documentation deficiency, while other recent investigations were clean. Overall, the facility appears to have isolated issues primarily around documentation and food storage, with no pattern of serious violations or fines.
The visit was an unannounced complaint investigation triggered by allegations received on 2025-06-02 regarding medication storage, dispensing by unqualified staff, disposal of spoiled medication, and sanitary practices during medication administration.
Findings
After interviews with staff and residents, review of medication procedures and training records, and medication audits, all allegations were found to be unsubstantiated due to insufficient evidence supporting violations. Medications were found to be properly secured, only qualified staff dispensed medications, spoiled medications were properly discarded, and sanitary practices were followed.
Complaint Details
The complaint investigation addressed allegations that staff did not keep medications centrally stored and secured, unqualified staff dispensed medications, spoiled medications were not properly discarded, and sanitary practices were not followed. The investigation found insufficient evidence to substantiate any of these allegations, deeming all unsubstantiated.
The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation (Complaint Control # 29-AS-20250602091623) to issue a citation for a deficiency observed during the complaint investigation.
Findings
Two out of two residents' medications reviewed revealed inaccurate medication record keeping, specifically medications were not accurately recorded on the centrally stored medication record log, posing a potential health, safety, or personal rights risk to persons in care.
Complaint Details
The visit was complaint-related, triggered by complaint #29-AS-20250602091623. The deficiency observed was substantiated and resulted in a citation.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Two out of two residents' medications were not accurately recorded on the centrally stored medication record log.
Type B
Report Facts
Residents medications reviewed: 2Capacity: 127Census: 75Plan of Correction Due Date: Sep 30, 2025
Employees Mentioned
Name
Title
Context
Zabel Chochian
Licensing Program Analyst
Conducted the Case Management - Deficiencies visit and complaint investigation.
The visit was an unannounced complaint investigation triggered by allegations that staff did not ensure residents were accorded reasonable accommodations and that staff were not properly addressing room repairs for residents in care.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident's request for room change and rent adjustment was not documented, and no water damage was observed. Maintenance staff responded promptly to flooding and plumbing issues, and minor repairs were generally addressed on the spot. Both allegations were deemed unsubstantiated.
Complaint Details
The complaint involved two main allegations: 1) staff failing to ensure residents received reasonable accommodations, specifically regarding a resident's request to move to a refurbished room and adjust rent, and 2) staff not properly addressing room repairs related to flooding and plumbing issues. The investigation included interviews, document reviews, and physical plant tours. Both allegations were found unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 127Census: 68Complaint Control Number: 29-AS-20241217100027 (alphanumeric)Monthly care fee: 42
Employees Mentioned
Name
Title
Context
Valeria Conway
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Desaree Perera
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
Aurora Israelson
Business Office Director
Met with Licensing Program Analyst during inspection and authorized report signing
Lilit Mnatsakanyam
Executive Director
Unavailable during visit but participated by phone; involved in investigation context
Terri Seifert
Former Executive Director
Interviewed regarding resident requests and maintenance issues
The inspection was a required annual unannounced visit conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.
Findings
The facility was generally found to be clean, well-maintained, and properly furnished with adequate safety features and proper temperature controls. However, a deficiency was cited for uncovered perishable food items stored in the freezer and refrigerator, posing a potential health and safety risk.
Deficiencies (1)
Description
Food such as vegetables, ice cream, pies and other items observed stored in the freezer and refrigerator uncovered, posing a potential health and safety risk to persons in care.
Report Facts
Deficiency due date: Jul 31, 2025Resident records reviewed: 8Personnel records reviewed: 8First aid kits: 2Rooms inspected: 8Floors inspected: 4Fire drill date: Jul 15, 2025Freezer temperature: 0Refrigerator temperature: 40Hot water temperature range: 105-120
Employees Mentioned
Name
Title
Context
Lilit Mnatsakanyan
Executive Director
Met with Licensing Program Analyst during inspection and involved in discussion of findings
Zabel Chochian
Licensing Program Analyst
Conducted the required annual inspection and signed the report
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2025-04-02 that staff do not prepare and serve food in a safe and healthful manner.
Findings
The investigation found that kitchen and dining staff who prepare food wore gloves and hair nets as required, and residents interviewed expressed satisfaction with the food service. There was insufficient evidence to support the allegation, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff do not prepare and serve food in a safe and healthful manner, specifically that kitchen and dining staff do not wear gloves or hair nets when handling food. The allegation was found unsubstantiated based on observations, staff interviews, resident interviews, and review of the facility's March 2025 Dietitian Report.
Report Facts
Residents interviewed: 10Capacity: 127Census: 72
Employees Mentioned
Name
Title
Context
Zabel Chochian
Licensing Program Analyst
Conducted the complaint investigation visit
Desaree Perera
Licensing Program Manager
Named in report signature and oversight
Patrice O'Grady
Administrator
Facility administrator named in report
Terri Seifer
Executive Director
Met with Licensing Program Analyst during investigation
Aurora Israelson
Business Office Director
Met with Licensing Program Analyst during investigation
An unannounced complaint investigation was conducted in response to an allegation that staff verbally abused a resident while in care.
Findings
The investigation found no evidence to support the allegation of verbal abuse by staff towards a resident. Interviews, document reviews, and observations did not reveal any immediate health or safety concerns. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that Staff #1 verbally abused Resident #1. Interviews with staff, residents, and the Executive Director, as well as document reviews, did not corroborate the allegation. A formal mediated meeting was held with no concerns noted. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Training hours completed: 27.5
Employees Mentioned
Name
Title
Context
Angela Barutyan
Licensing Program Analyst
Conducted the complaint investigation.
Kristin Heffernan
Licensing Program Manager
Named as Licensing Program Manager on the report.
Terri Seifert
Executive Director
Met with Licensing Program Analyst during investigation and involved in discussions about the allegation.
Patrice O'Grady
Administrator
Facility Administrator named in the report.
Inspection Report Original LicensingCensus: 68Capacity: 127Deficiencies: 0Jul 19, 2024
Visit Reason
This was a pre-licensing visit conducted as part of a Change of Ownership Application (CHOW) for the facility currently operating under a different license number. The visit was to evaluate the facility prior to licensing approval.
Findings
The facility was found to be in good condition with no corrections required at this time. Resident rooms, common areas, and safety features were inspected and found adequate. Records, medication storage, and emergency preparedness were reviewed and found to be in order.
Report Facts
Residents present: 68Total licensed capacity: 127Rooms inspected: 8Resident records reviewed: 6Personnel records reviewed: 6Last emergency drill date: Jul 9, 2024Hot water temperature: 113
Employees Mentioned
Name
Title
Context
Patrice O'Grady
Executive Director
Met with Licensing Program Analysts during the pre-licensing visit
Valeria Conway
Licensing Program Analyst
Conducted the pre-licensing visit and signed the report
Brian Balisi
Licensing Program Analyst
Conducted the pre-licensing visit
Desaree Perera
Licensing Program Manager
Named as Licensing Program Manager on the report
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