Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations resulting in unsubstantiated allegations related to resident care, staff training, and communication. However, some deficiencies were cited in 2025, including serious issues such as failure to notify licensing of an alleged abuse incident in a timely manner and inadequate documentation and policy for resident checks, both posing immediate health and safety risks. The facility also faced substantiated findings for infection control lapses during a COVID outbreak in late 2023. The most recent report from October 22, 2025, identified a deficiency involving undocumented resident checks, indicating ongoing challenges in supervision and documentation. While some reports show improvement in areas like medication management and incident reporting, the facility has had intermittent serious concerns primarily related to resident safety and abuse reporting.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Capacity: 127
Deficiencies: 1
Oct 22, 2025
Visit Reason
The inspection was a case management visit conducted in relation to complaint #14-AS-20250113154240 to investigate resident checks for Resident 1 (R1).
Findings
The investigation found that resident checks for R1 were conducted randomly or every couple of hours without documentation of when, who conducted the checks, or observations made. Staff could not recall observations but claimed checks were done. This lack of policy and documentation poses an immediate health and safety risk.
Complaint Details
The visit was triggered by complaint #14-AS-20250113154240. The report does not explicitly state substantiation status.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| No definitive policy or documentation requirements for conducting resident checks as to date, time, observations, or who conducted the resident checks for R1, posing an immediate health and safety risk. | Type A |
Report Facts
Facility capacity: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the case management visit and investigation |
| Tammie Sampedro | Regional Operations Specialist | Met with during the visit and reviewed the report |
| Kathleen Olson | Administrator/Director | Facility administrator interviewed regarding policies |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Follow-Up
Census: 69
Capacity: 127
Deficiencies: 1
Aug 6, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on a previous visit regarding an alleged abuse incident involving a staff member and a resident.
Findings
The administrator failed to notify the Community Care Licensing Division (CCLD) of an alleged abuse incident for 5 days after becoming aware of it and delayed submitting required incident reports, posing an immediate health and safety risk to residents.
Complaint Details
The visit was complaint-related, triggered by an allegation that a staff member took an unauthorized video of a resident sleeping and physically abused the resident. The complaint was substantiated by the licensing agency.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator failed to notify CCLD of an alleged abuse incident that occurred on 7/9/25 and was made aware on 7/12/25, with notification delayed by 5 days and incident report submitted late, posing immediate health and safety risk. | Type A |
Report Facts
Days delayed in reporting: 5
Capacity: 127
Census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Olson | Interim Executive Director | Met with Licensing Program Analyst during the inspection and involved in the incident reporting. |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Siobhan Surraco | Administrator/Director | Failed to timely notify CCLD of the alleged abuse incident. |
Inspection Report
Census: 69
Capacity: 127
Deficiencies: 0
Aug 5, 2025
Visit Reason
The visit was an unannounced case management visit to deliver an immediate exclusion letter to exclude Staff #1 (S1) from the facility.
Findings
The Licensing Program Analyst delivered an immediate exclusion letter to the Interim Executive Director, Kathleen Olson, excluding Staff #1 from the facility. The report was reviewed and discussed with the Interim Executive Director and a copy was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Olson | Interim Executive Director | Met with Licensing Program Analyst during the visit and received the immediate exclusion letter. |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the immediate exclusion letter. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 127
Deficiencies: 0
Jul 22, 2025
Visit Reason
An unannounced case management visit was conducted in relation to an incident reported involving alleged unauthorized video recording and physical abuse of a resident by a staff member.
Findings
The investigation revealed that Staff 1 took an unauthorized video of Resident 1 while the resident was sleeping and physically abused the resident. Staff 1 resigned during the investigation. Further investigation is required.
Complaint Details
The visit was complaint-related due to an incident reported on 7/9/25 involving alleged physical abuse and unauthorized video recording by Staff 1. The complaint was reported on 7/12/25. Staff 1 resigned during the investigation.
Report Facts
Date of incident: Jul 9, 2025
Date complaint reported: Jul 12, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Kathleen Olson | Interim Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 127
Deficiencies: 0
Jun 18, 2025
Visit Reason
An unannounced case management visit was conducted in relation to an incident on 2025-05-31 where a resident reported taking over seven days of medication at one time and expressed suicidal ideation.
Findings
The investigation found that the resident was initially able to manage their own medications but after the incident was diagnosed with early onset Alzheimer's dementia and is now unable to manage medications. The facility has implemented a 1:1 caregiver and is managing the resident's medications. No citations were issued.
Complaint Details
The complaint involved a resident who took multiple days' worth of medication at once and expressed suicidal thoughts. The resident was hospitalized and later returned with increased supervision and medication management by the facility. The complaint was investigated and no citations were issued.
Report Facts
Incident date: May 31, 2025
Resident return date: Jun 16, 2025
Caregiver supervision duration: 72
Behavioral therapy frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Siobhan Surraco | Administrator | Met with Licensing Program Analyst during visit and involved in incident review |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Follow-Up
Census: 59
Capacity: 127
Deficiencies: 1
May 27, 2025
Visit Reason
The visit was an unannounced case management follow-up conducted on May 27, 2025, to review a previous incident where a resident exited a secured memory care unit unattended.
Findings
The report found that Resident 1, diagnosed with dementia, left the secured memory care unit unattended and was found a block away from the facility, posing an immediate health and safety risk. Deficiencies were cited related to care and supervision.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on interviews, observations and record reviews, Resident 1 has dementia and left the unit/facility unattended and was found a block away from the facility which poses an immediate health and safety risk to residents in care. | Type A |
Report Facts
Capacity: 127
Census: 59
Plan of Correction Due Date: May 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the inspection and authored the report |
| Edward DeWitt | Resident Services Director | Met with the Licensing Program Analyst during the visit |
| April Cowan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 58
Capacity: 127
Deficiencies: 0
May 15, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on an incident that occurred on 2025-05-01 involving a resident who exited the secured memory care unit without staff supervision.
Findings
The resident was found unharmed outside the facility. Both delayed egress doors were functioning properly. The facility staff and administrator were unsure how the resident left without staff noticing, possibly during shift change. No citations were issued during the visit.
Report Facts
Incident date: May 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Siobhan Surraco | Administrator | Met with Licensing Program Analyst during visit and involved in incident review |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 55
Capacity: 127
Deficiencies: 0
Oct 31, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, odor-free, and free from hazards. Resident and staff records were complete and up to date. No deficiencies were cited at this time, though some documents were requested for submission by 11/7/2024.
Report Facts
Days observed for perishables: 2
Days observed for non-perishables: 7
Resident records reviewed: 5
Staff records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Siobahn Surraco | Administrator | Met with Licensing Program Analyst during inspection |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection |
| April Cowan | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 127
Deficiencies: 0
May 10, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations received regarding resident care and safety at the facility.
Findings
The investigation found that residents are not intentionally locked in their rooms, there was insufficient evidence to confirm elopements, and allegations related to feeding, dressing, and hygiene needs were unsubstantiated based on interviews and observations.
Complaint Details
The complaint included allegations that staff locked residents in their rooms, residents eloped from the facility, staff did not report unusual incidents to residents' representatives, and staff failed to feed, dress, or provide hygiene needs to residents. All allegations were found to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 127
Census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Siobhan Surraco | Administrator | Met with Licensing Program Analyst during the investigation |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 127
Deficiencies: 0
Feb 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to deliver findings regarding allegations received about staff behavior, water temperature during showers, and incident reporting.
Findings
The investigation found conflicting statements between residents and staff, confirmed warm water delivery during showers, and determined no preponderance of evidence to substantiate the allegations. Therefore, all allegations were unsubstantiated.
Complaint Details
The complaint included allegations that staff spoke to a resident in an inappropriate manner, staff did not ensure faucet was delivering warm water during showers, staff threatened a resident, and the facility failed to report an incident to licensing. These allegations were found unsubstantiated.
Report Facts
Capacity: 127
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Siobhan Surraco | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 45
Capacity: 127
Deficiencies: 0
Jan 10, 2024
Visit Reason
An unannounced case management visit was conducted to deliver an amended complaint report for complaint #14-AS-20231205135135.
Findings
The Licensing Program Analyst delivered amended findings for the specified complaint and reviewed the report with the interim executive director. The report was marked public as it was previously marked confidential in error.
Complaint Details
The visit was related to complaint #14-AS-20231205135135; amended findings were delivered and the report was made public.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Pryor | Interim Executive Director | Met with Licensing Program Analyst during the visit and reviewed the amended complaint report. |
| Jaime Vado | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the amended complaint report. |
| April Cowan | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 127
Deficiencies: 0
Jan 10, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-08-03 regarding allegations that a resident sustained injuries while in care and that staff were not fully trained.
Findings
The investigation found that staff are regularly trained throughout the year and that the resident's injuries were due to documented falls related to physical limitations, not other causes. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint involved allegations of resident injuries and insufficient staff training. The investigation concluded these allegations were unsubstantiated.
Report Facts
Capacity: 127
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Pryor | Interim Executive Director | Met with the Licensing Program Analyst during the investigation |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Layana Santos | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 127
Deficiencies: 0
Jan 10, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not responding to resident's representative's requests for communication in a timely manner.
Findings
The investigation included interviews and review of communication protocols during a COVID outbreak. Evidence showed responsible parties were contacted via email and meetings were held with family members. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff were not responding timely to resident representatives' communication requests. The investigation found that emails and meetings were conducted to inform families, and the allegations were unsubstantiated.
Report Facts
Complaint control number: 14
Facility capacity: 127
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| April Cowan | Licensing Program Manager | Named in report signature and oversight |
| Layana Santos | Administrator | Facility administrator at time of report |
| Jessica Pryor | Interim Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Meghan Leone | Previous Executive Director | Provided information and documentation regarding COVID outbreak communication |
Inspection Report
Annual Inspection
Census: 43
Capacity: 127
Deficiencies: 0
Dec 14, 2023
Visit Reason
An unannounced required 1 year annual inspection visit was conducted to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be clean, safe, and well-maintained with all required safety equipment and supplies in place. No citations were issued during the inspection.
Report Facts
Water temperature: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the inspection visit |
| Eugenia Smith | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| Layana Santos | Administrator | Facility administrator named in report |
| April Cowan | Licensing Program Manager | Named in report |
Inspection Report
Original Licensing
Census: 43
Capacity: 127
Deficiencies: 0
Dec 14, 2023
Visit Reason
An unannounced post licensing inspection visit was conducted to evaluate the facility's compliance with regulatory requirements following licensing.
Findings
The facility was toured inside and outside, including the memory care building, and found to be clean, safe, and well-maintained with all required safety equipment and supplies in place. No citations were issued.
Report Facts
Water temperature: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugenia Smith | Interim executive director | Met with Licensing Program Analyst during inspection |
| Layana Santos | Administrator | Named as facility administrator |
| Jaime Vado | Licensing Program Analyst | Conducted the inspection visit |
| April Cowan | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 127
Deficiencies: 1
Dec 14, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-07-25 alleging that staff were not following infection control requirements.
Findings
The investigation found that there were insufficient COVID test kits during an outbreak in memory care, and isolation procedures, social distancing, signage, hand sanitizer, gowns, and masking requirements were not fully adhered to. Residents congregated despite COVID status and PPE use was lacking, substantiating the allegation.
Complaint Details
The complaint was substantiated based on interviews and evidence reviewed by Licensing Program Analyst Jaime Vado. The allegation involved failure to follow infection control requirements during a COVID outbreak.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not have enough COVID test kits to test residents with symptoms in memory care; isolation procedures, social distancing, appropriate signs, hand sanitizer, gowns, and masking requirements were not fully adhered to during the outbreak, resulting in unsafe and unhealthful accommodations for residents. | Type A |
Report Facts
Capacity: 127
Census: 43
Deficiencies cited: 1
Plan of Correction Due Date: Dec 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ana Gobeleza | Business Office Director | Met with Licensing Program Analyst during investigation |
| Layana Santos | Administrator | Facility administrator named in the report |
| Meghan Leone | Previous Administrator | Interviewed during investigation |
| Cara Smith | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 127
Deficiencies: 0
Dec 14, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that staff did not assist a resident to and from the restroom.
Findings
The investigation found that staff did not witness the alleged incident and the resident went to the restroom unassisted without calling for help. The allegation was determined to be unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged that staff did not assist a resident to and from the restroom. The allegation was unsubstantiated after investigation, as staff did not observe the incident and the resident did not request assistance.
Report Facts
Complaint received date: Sep 19, 2023
Complaint control number: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ana Gobeleza | Business Office Director | Met with during the investigation and reviewed findings |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 127
Deficiencies: 0
Dec 14, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations of staff mismanaging residents' medication and untrained staff.
Findings
The investigation found that medication administration practices, med cart organization, medication administration recording process, and training records were all in place and current. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated as there was no sufficient evidence to prove the alleged violations regarding medication mismanagement and untrained staff.
Report Facts
Capacity: 127
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jessica Pryor | Interim Executive Director | Met with Licensing Program Analyst during the investigation |
| Layana Santos | Administrator | Facility administrator named in the report |
| April Cowan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 127
Deficiencies: 0
Aug 16, 2023
Visit Reason
An unannounced case management - incident investigation visit was conducted to investigate an incident involving resident R1, specifically a possible fall that may have occurred on 08/15/2023.
Findings
The circumstances of the incident involving resident R1 were unclear and unseen. The facility was within the required reporting timeframe and was in the process of submitting an incident report to the Department. No citations were issued during this visit.
Complaint Details
The visit was complaint-related, investigating an incident involving a possible fall of resident R1 on 08/15/2023. The incident was not substantiated with citations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the unannounced case management - incident investigation visit. |
| Megan Leone | Administrator | Met with Licensing Program Analyst during the visit and explained the purpose of the visit. |
| Bernadette King | Memory Care Coordinator | Attended the visit and was present during the discussion of the incident. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 127
Deficiencies: 0
May 3, 2023
Visit Reason
An unannounced case management visit was conducted regarding missing narcotics discovered during routine medication audits on 04/29/2023 and 04/30/2023, reported to the Department on 05/01/2023.
Findings
The facility reported missing narcotics prescribed as needed, with no missed dosages for residents. The facility is actively investigating the situation, including medication audits and reviewing staff, with narcotics securely stored and access limited to staff. No citations were issued as the investigation is ongoing.
Complaint Details
The visit was complaint-related due to missing narcotics. The facility reported the loss to the Department and local Sheriff's Department, and the investigation is ongoing with no citations at this time.
Report Facts
Census: 41
Total Capacity: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Bruhn | Interim Administrator | Met with Licensing Program Analyst during the visit |
| Jo Marie Ghersi | Health Care Manager | Discussed missing narcotics and medication audits |
Inspection Report
Original Licensing
Capacity: 127
Deficiencies: 0
Dec 16, 2021
Visit Reason
The visit was an announced prelicensing inspection conducted to evaluate the facility for licensure and ensure compliance with regulatory requirements.
Findings
The facility was toured and inspected thoroughly, including medication rooms, kitchen, resident rooms, and safety systems. The facility was found fully functional and in place, with no citations issued. Water temperatures and safety features were checked and found compliant.
Report Facts
Water temperature: 107
Water temperature: 115
Emergency generator runtime hours: 72
Number of medication rooms: 5
Number of resident rooms on ground floor: 5
Number of rooms in dementia area on second floor: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abbie Apolinario | Administrator | Met with Licensing Program Analysts during inspection |
| Jason Englehorn | Senior Vice President of Operations for New Developments | Met with Licensing Program Analysts during inspection |
| Jaime Vado | Licensing Program Analyst | Conducted the inspection visit |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection visit |
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