Inspection Report
Annual Inspection
Census: 92
Capacity: 140
Deficiencies: 0
Oct 2, 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 generally compliant with no health and safety hazards noted. The physical plant was toured, and areas such as fire safety, food storage, cleanliness, and resident accommodations were inspected and found satisfactory.
Report Facts
Fire extinguisher last inspection date: Oct 15, 2024
Hot water temperature: 118.3
Facility capacity: 140
Resident census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and met with facility representative |
| Tamara Berry | Administrator | Named as facility administrator |
Inspection Report
Annual Inspection
Census: 128
Capacity: 140
Deficiencies: 0
Oct 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 found to be in good condition.
Report Facts
Number of bedrooms: 86
Hot water temperature: 117.4
Fire extinguisher last inspection date: Oct 6, 2023
Perishable food stock duration: 2
Non-perishable food stock duration: 7
Facility temperature: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Met with facility representative and conducted inspection |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
| Monica Chifamba | Met with Licensing Program Analyst during inspection | |
| Tamara Berry | Administrator/Director | Facility Administrator/Director |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 140
Deficiencies: 0
Mar 13, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that a resident developed pressure injuries due to neglect.
Findings
The investigation found insufficient evidence to substantiate the allegation. The resident's pressure injuries progressed under hospice care, and staff reported following care instructions including turning the resident every two hours. No health and safety hazards were noted during the visit.
Complaint Details
The complaint alleged that Resident #1 developed pressure injuries due to neglect, specifically from not being turned enough. The allegation was unsubstantiated based on record review and staff interviews.
Report Facts
Staff providing hands on care per shift: 6
Residents per staff: 4
Residents per staff: 6
Pressure injury stages: 2
Pressure injury stages: 3
Pressure injury stages: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Berry | Executive Director | Met with during investigation and named in relation to the complaint |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 140
Deficiencies: 0
Mar 18, 2023
Visit Reason
Unannounced visit to investigate a complaint alleging staff not supervising a resident resulting in multiple falls and injuries.
Findings
The investigation found that the resident had multiple falls but the facility had implemented necessary protocols including increased care and safety measures to prevent further falls. The allegation was deemed unsubstantiated.
Complaint Details
Complaint was unsubstantiated after investigation. The resident had a history of falls and injuries, but the facility provided increased assistance, a 1:1 companion for 72 hours, and safety equipment such as a fall mat and Halo rail to prevent falls.
Report Facts
Complaint Control Number: 31
Complaint received date: Aug 10, 2020
Resident 1 companion hours: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Michelle M Johnson | Administrator | Facility administrator named in report header |
| Debbie Gutierrez | Reminiscence Coordinator | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 140
Deficiencies: 0
Dec 28, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility is understaffed and residents are not being checked regularly.
Findings
Interviews with residents and staff revealed that the majority believe there is sufficient staffing and residents receive adequate care. Based on gathered information, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged understaffing and insufficient resident checks. Interviews with 14 residents showed 11 believed staffing was sufficient. Staff interviews showed 8 out of 10 believed staffing was adequate. The allegation was unsubstantiated.
Report Facts
Residents interviewed: 14
Residents agreeing sufficient staffing: 11
Staff interviewed: 10
Staff agreeing sufficient staffing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Michelle M Johnson | Administrator | Facility administrator named in report header |
| Tammy Berry | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 128
Capacity: 140
Deficiencies: 0
Sep 27, 2022
Visit Reason
Licensing Program Analyst Angela Panushkina conducted an Annual Required visit and inspection of the facility to ensure compliance with licensing requirements.
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
Non-perishable food stock duration: 7
Perishable food stock duration: 2
Fire alarm inspection date: Oct 13, 2021
Fire extinguisher service date: Apr 18, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the annual required visit and inspection |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Tamara Berry | Administrator | Facility Administrator |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 140
Deficiencies: 0
Sep 14, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained multiple falls while in care.
Findings
The investigation included interviews with staff, residents, and the resident's Power of Attorney, as well as a review of relevant documents. The allegation that the resident had multiple falls while intoxicated was found to be unsubstantiated based on the information gathered.
Complaint Details
The complaint alleged that Resident #1 sustained multiple falls while in care. The investigation found that the resident used alcohol and was intoxicated during the fall incident, but the facility was following doctor's orders and monitoring the resident's alcohol intake. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 140
Census: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
| Tamara Berry | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 117
Capacity: 140
Deficiencies: 0
Oct 14, 2021
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and infection control recommendations.
Findings
The facility was found to be generally compliant with no deficiencies issued. Infection control measures, food storage, safety systems, resident rooms, medication security, and outdoor areas were all observed to meet regulatory standards.
Report Facts
Hot water temperature: 111.3
Hot water temperature: 116.5
Food shelf life: 10
Medication carts observed: 2
Staff response count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Berry | Administrator | Met with Licensing Program Analysts during inspection |
| Angela Panushkina | Licensing Program Analyst | Conducted the inspection |
| Shira Stamps | Licensing Program Analyst | Conducted the inspection |
| Nichelle Gillyard | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 140
Deficiencies: 0
Aug 24, 2021
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations that residents were left in soiled diapers and residents were not being provided medication.
Findings
The investigation found no evidence to substantiate the allegations. Interviews with staff and residents confirmed no residents were left in soiled diapers and no residents missed medication, although some limited delays in medication administration were acknowledged.
Complaint Details
The complaint was unsubstantiated based on interviews with the Executive Director, Assisted Living Coordinator, care staff, Resident Care Director, medication technicians, and residents. No reports or observations confirmed the allegations.
Report Facts
Capacity: 140
Census: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tammy Berry | Executive Director | Met with Licensing Program Analyst during investigation |
| Michelle M Johnson | Administrator | Facility administrator named in report header |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 140
Deficiencies: 0
Jun 25, 2021
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that the admission agreement does not identify itemized description of charges for resident(s) services.
Findings
The investigation found that the admission agreement contained all details of potential charges depending on the level of care with corresponding prices. The allegation was deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on the investigation findings.
Report Facts
Capacity: 140
Census: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| LaQueena Lacy | Licensing Program Analyst | Conducted the complaint investigation |
| Tammy Berry | Executive Director | Met with investigators during the complaint visit |
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