Inspection Report Summary
Most inspections found some deficiencies, with the latest annual inspection on February 20, 2025, identifying issues including improper storage of cleaning chemicals in a resident’s room, a staff member lacking criminal record clearance, and missed quarterly emergency drills. Earlier annual inspections also noted missing health screenings for staff and incomplete hospice training, while complaint investigations from 2023 and 2024 mostly found allegations unsubstantiated except for one substantiated complaint in February 2023 related to failure to provide resident records to an authorized person. None of the reports indicated fines, license suspensions, or immediate jeopardy, and the deficiencies were generally isolated rather than severe. The facility showed some ongoing challenges with staff compliance and emergency preparedness, but the most recent report suggests these issues continue to require attention. Several complaint investigations were unsubstantiated, indicating that many concerns raised were not confirmed upon review.
Deficiencies (last 3 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a February 2025 inspection.
Occupancy over time
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Sarah St. Charles | Executive Director | Oversees entire building including licensed facility |
| Novie Villafuerte | Certified RCFE Administrator | Oversees facility operations |
| Audrey Jeung | Licensing Program Analyst / Evaluator | Conducted inspection and signed report |
| April Cowan | Licensing Program Manager / Supervisor | Supervisor for the inspection and cited deficiencies |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Sarah St. Charles | Administrator | Certified RCFE administrator overseeing facility operations. |
| Novie Villafuerte | Administrator | Certified RCFE administrator overseeing facility operations. |
| Cara Smith | Licensing Program Manager | Named in relation to supervision and deficiency enforcement. |
| Audrey Jeung | Licensing Program Analyst/Evaluator | Conducted the inspection and signed the report. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cara Smith | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Sarah St. Charles | Executive Director | Met with Licensing Program Analyst during investigation and acknowledged facility's failure to provide records |
| Novie-Ann Villafuerte | Director of Assisted Living | Met with Licensing Program Analyst during investigation |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cara Smith | Licensing Program Manager | Reviewed report and responsible for licensing oversight |
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