Inspection Report Summary
Most inspections found no deficiencies, with the facility consistently clean, well-maintained, and compliant with safety and licensing requirements. A complaint investigation on July 25, 2024, substantiated an issue with intermittent hot water since February 2024, which posed a potential health and safety risk; the facility took steps to repair this problem. Other complaint investigations, including one in August 2023 about medication administration, were unsubstantiated. The most recent report from September 12, 2025, showed no deficiencies and confirmed the facility remained in good condition. This indicates improvement since the hot water issue was resolved and no new concerns have been noted.
Deficiencies per Year
4
3
2
1
0
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 97
Capacity: 121
Deficiencies: 0
Sep 12, 2025
Visit Reason
The inspection was a required one-year unannounced visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and properly furnished with no health or safety hazards noted. All safety equipment was inspected and functional, and medication and hazardous materials were securely stored.
Report Facts
Licensed capacity: 121
Current census: 97
Resident rooms: 86
Hospice waiver capacity: 15
Fire extinguisher last inspection date: Jan 14, 2025
Average hot water temperature: 115.2
Perishable food stock: 2
Non-perishable food stock: 7
Facility temperature: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tom Park | Executive Director | Met with Licensing Program Analyst during inspection |
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and authored the report |
| Troy Agard | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 99
Capacity: 121
Deficiencies: 0
Sep 6, 2024
Visit Reason
The inspection was a required one-year unannounced visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and properly stocked with necessary supplies. No health or safety hazards were noted, and all safety equipment was inspected and functional. Resident rooms and common areas were adequately furnished and sanitary.
Report Facts
Facility capacity: 121
Current census: 99
Fire extinguisher last inspection date: Jan 12, 2024
Hot water temperature: 117.4
Perishable food stock: 2
Non-perishable food stock: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tom Park | Executive Director | Met with Licensing Program Analyst during inspection |
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and authored the report |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 121
Deficiencies: 1
Jul 25, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility hot water was in disrepair and residents were unable to take hot showers.
Findings
The allegation was substantiated based on interviews and record review. Hot water was intermittently unavailable since 02/27/2024, posing a potential health, safety, and personal rights risk to residents. The facility took necessary measures to repair the hot water, with observed temperature at 111.4°F during the visit.
Complaint Details
The complaint was substantiated. It was alleged that the facility had intermittent hot water since 02/27/2024 and residents complained about not being able to take hot showers. Interviews with staff and review of work orders confirmed the issue. Staff #3 reported wiring and parts issues, with a third-party company contacted to resolve the problem.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87303 Maintenance and Operation (a): The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by intermittent lack of hot water posing a potential health, safety and personal rights risk to residents. | Type B |
Report Facts
Facility Capacity: 121
Census: 97
Hot Water Temperature: 111.4
Deficiency Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tom Park | Executive Director | Facility administrator met during the investigation |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 121
Deficiencies: 0
Aug 30, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that facility staff were dispensing medication not prescribed to a resident.
Findings
The investigation found that the resident was self-administering their own medication and the allegation was unsubstantiated based on interviews and record reviews, including lab tests negative for methadone.
Complaint Details
The complaint alleged that facility staff were dispensing Methadone medication not prescribed to Resident #1. The allegation was found to be unsubstantiated after interviews with the resident and administrator, and review of lab results and records.
Report Facts
Facility capacity: 121
Resident census: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Tom Park | Executive Director | Facility administrator interviewed during investigation |
Inspection Report
Annual Inspection
Census: 94
Capacity: 121
Deficiencies: 0
Sep 21, 2022
Visit Reason
Licensing Program Analyst Angela Panushkina conducted an Annual Required visit and inspection of the facility to evaluate compliance with licensing regulations.
Findings
The facility was found to be in compliance with no deficiencies cited. Observations included proper infection control measures, sanitary kitchen and dining areas, functional fire safety equipment, well-maintained common and resident areas, and proper documentation in resident and staff files.
Report Facts
Rooms: 86
Fire alarm inspection date: Dec 22, 2021
Fire extinguisher service date: Feb 7, 2022
PPE supply duration: 30
Non-perishable food stock duration: 7
Perishable food stock duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Tom Park | Executive Director | Facility administrator met with Licensing Program Analyst during inspection |
| Nichelle Gillyard | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Census: 93
Capacity: 121
Deficiencies: 0
May 24, 2022
Visit Reason
The case management visit was conducted to confirm the removal of a staff member from the facility.
Findings
The Licensing Program Analyst verified that the staff member was no longer employed or present at the facility and advised the administrator to disassociate the individual from the roster. No health or safety issues were observed during the physical plant tour.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tom Park | Executive Director | Met with Licensing Program Analyst during case management visit. |
| Angela Panushkina | Licensing Program Analyst | Conducted the case management visit and verification of staff removal. |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Original Licensing
Census: 91
Capacity: 121
Deficiencies: 0
Sep 23, 2021
Visit Reason
An announced Pre-Licensing visit was conducted as part of a change of ownership application for the facility.
Findings
The facility was inspected for fire safety, personal accommodations, food service, medication procedures, and records. The facility was found to be in compliance with Title 22 Regulations at the time of the visit.
Report Facts
Bedridden residents: 5
Hospice residents: 5
Hospice waiver: 12
Fire clearance date: Jul 21, 2021
Fire extinguisher last serviced: Jan 18, 2021
Water temperature range: 114.8-118.2
Facility capacity: 121
Current census: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tom Park | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Angela Panushkina | Licensing Program Analyst | Conducted the Pre-Licensing visit and inspection. |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Original Licensing
Capacity: 121
Deficiencies: 0
Aug 20, 2021
Visit Reason
The visit was conducted as part of the original licensing process involving a Component II telephone call to verify the applicant/administrator's understanding of Title 22 and related regulatory requirements.
Findings
The applicant/administrator successfully completed Component II via telephone call, confirming understanding of facility operation, staff qualifications, program policies, and other licensing requirements. No deficiencies or violations were noted in the report.
Report Facts
Capacity: 121
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tom Park | Administrator | Applicant/administrator who participated in the Component II telephone call |
| Mirella Quaranta | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Stefania Fonteno | Licensing Program Analyst | Named as Licensing Program Analyst on the report |
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