Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating the facility generally meets licensing requirements and resident care standards. The most recent report from October 2, 2025, showed no deficiencies and found the facility clean, safe, and well-maintained. Earlier complaints about neglect, falls, understaffing, and medication issues were all investigated and not substantiated. The facility’s record shows consistent compliance with infection control, safety, and documentation standards over time. There is no indication of fines, enforcement actions, or severe issues in the available reports.
Deficiencies (last 5 years)
Deficiencies (over 5 years)0 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
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, 2024Hot water temperature: 118.3Facility capacity: 140Resident census: 92
Employees Mentioned
Name
Title
Context
Abeye Duguma
Licensing Program Analyst
Conducted the inspection and met with facility representative
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: 86Hot water temperature: 117.4Fire extinguisher last inspection date: Oct 6, 2023Perishable food stock duration: 2Non-perishable food stock duration: 7Facility 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
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: 6Residents per staff: 4Residents per staff: 6Pressure injury stages: 2Pressure injury stages: 3Pressure injury stages: 4
Employees Mentioned
Name
Title
Context
Tamara Berry
Executive Director
Met with during investigation and named in relation to the complaint
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: 31Complaint received date: Aug 10, 2020Resident 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
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.
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.
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.
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: 111.3Hot water temperature: 116.5Food shelf life: 10Medication carts observed: 2Staff response count: 3
Employees Mentioned
Name
Title
Context
Tamara Berry
Administrator
Met with Licensing Program Analysts during inspection
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: 140Census: 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
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: 140Census: 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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