Most inspections found no deficiencies, including the most recent annual inspection on July 3, 2025, which was clean and found the facility sanitary and compliant with infection control practices. Earlier reports from May and June 2024 focused on licensing preparations, with the May 30, 2024 pre-licensing visit identifying several minor deficiencies such as securing the garage door, fixing a plumbing drain overflow, and patching a hole in a resident room wall. These issues were addressed by the June 12, 2024 follow-up visit, which found the facility ready for licensing. There were no complaints or enforcement actions reported, and no fines or severe deficiencies appeared in the records. The overall trend shows improvement from initial minor corrections to a fully compliant and well-maintained facility.
An unannounced required 1-Year annual visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. No deficiencies were cited during the inspection visit.
Facility representative met during inspection and exit interview
Inspection Report Original LicensingCensus: 6Capacity: 6Deficiencies: 0Jun 12, 2024
Visit Reason
The inspection visit was conducted as a prelicensing follow-up to verify corrections identified during the initial prelicensing visit on 05/30/2024 for a Residential Facility Care for the Elderly with a change of ownership.
Findings
The Licensing Program Analyst observed that all noted items from the previous visit had been addressed, including repairs to the plumbing drain, resident room wall, and verification of water temperature. The facility was found ready to be licensed.
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the inspection visit and observed compliance with prelicensing corrections.
Vijay Kanase
Licensee/Administrator
Met with Licensing Program Analyst during the inspection and discussed the purpose of the visit.
Inspection Report Original LicensingCensus: 5Capacity: 6Deficiencies: 5May 30, 2024
Visit Reason
Licensing Program Analyst Jenifer Tirre visited the facility to conduct a pre-licensing evaluation for initial licensing of the facility.
Findings
The facility was inspected and found to meet many licensing requirements including fire clearance, adequate bedrooms and bathrooms, emergency plans, and operational appliances. However, several corrections were required before licensing could be granted, including securing the garage door, obtaining an approved First Aid Handbook, ensuring gates are self-latching, repairing a plumbing drain overflow, and patching a hole in a resident room wall.
Deficiencies (5)
Description
Garage door to have secure locked door knob upon entrance
Facility to obtain Proper approved First Aid Handbook
Gates need to be self latching per regulations
Outside passageway plumbing drain overflow causing potential fall risk hazard
Resident Room 3 needs hole in wall patched and repaired
Report Facts
Capacity: 6Census: 5Water temperature range: 119.8Water temperature range: 123Fire clearance approval date: Jan 30, 2024
Employees Mentioned
Name
Title
Context
Jenifer Tirre
Licensing Program Analyst
Conducted the pre-licensing evaluation and authored the report
Vijay Kanase
Administrator/Licensee
Facility Administrator and Licensee present during inspection
The visit was an office evaluation related to a change of ownership (CHOW) application for the facility.
Findings
The applicant/administrator participated in a virtual interview to verify understanding of community care facility licensing laws and readiness in areas including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
Employees Mentioned
Name
Title
Context
Vijay Kanase
Corporate Board Member/Administrator
Participant in the COMP II interview and applicant/administrator verified during the evaluation.
Darla Neeley
Licensing Program Manager
Named as Licensing Program Manager overseeing the evaluation.
Diamond Law
Licensing Program Analyst
Named as Licensing Program Analyst involved in the evaluation.
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