Inspection Report
Deficiencies: 0
Aug 4, 2025
Visit Reason
The inspection was conducted as a physical plant tour of the building and grounds of the facility to review compliance with applicable standards and laws.
Findings
The inspection found no violations with applicable standards or laws during the visit.
Inspection Report
Deficiencies: 0
Jun 30, 2025
Visit Reason
The inspection was conducted as a physical plant tour of the building and grounds of the assisted living facility to review compliance with applicable standards.
Findings
The inspection found no violations with applicable standards or laws during the visit.
Inspection Report
Monitoring
Census: 25
Deficiencies: 1
Jan 2, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with building and grounds standards following a self-reported incident regarding bedbug infestations.
Findings
The facility was found to be non-compliant due to an infestation of bedbugs, confirmed by staff acknowledgments and pest control treatment documentation. A plan of correction was submitted outlining initial response, treatment, long-term pest control, and monitoring measures.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the building was kept free of infestations of insects and vermin, specifically bedbugs. |
Report Facts
Number of residents present: 25
Pest control treatment dates: 2
Pest control program duration: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Renewal
Census: 25
Deficiencies: 7
Jan 2, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable regulations and licensing requirements at Commonwealth Senior Living at the Devonshire.
Findings
The inspection identified multiple violations including failure to post the current license conspicuously, missing disclosure statements and written assurances in resident records, lack of current first aid certification for direct care staff, improper hot water temperatures, and failure to post recent inspection findings. Plans of correction were provided for each violation.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure that the current license was posted in a place conspicuous to residents and the public. |
| Facility failed to provide disclosure statements to prospective residents and their legal representatives. |
| Direct care staff member did not maintain current certification in first aid. |
| Facility failed to provide written assurance of appropriate license to residents prior to admission. |
| Facility failed to have admission agreements with residents after change in ownership. |
| Hot water temperature at taps available to residents exceeded the required range of 105°F to 120°F. |
| Facility failed to post findings of the most recent inspection on the premises. |
Report Facts
Number of residents present: 25
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Hot water temperature: 122.3
Hot water temperature: 128.1
Date of ownership change: Aug 21, 2024
Date of first aid certification class: Jan 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Conducted the inspection |
| Staff #2 | Acknowledged multiple deficiencies including missing license posting, missing disclosure statements, missing written assurances, and missing admission agreements | |
| Staff #3 | Direct care staff without current first aid certification | |
| Executive Director | Responsible for posting license, conducting audits, and implementing plans of correction | |
| Business Office Manager | Responsible for auditing resident files and staff certifications | |
| Maintenance Director | Responsible for adjusting water heater and conducting monthly water temperature checks |
Inspection Report
Monitoring
Census: 30
Deficiencies: 4
Oct 24, 2024
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at Commonwealth Senior Living at the Devonshire.
Findings
The inspection found multiple violations related to failure to update disclosure statements after a change in ownership, failure to maintain current first aid/CPR certification postings, lack of admission agreements in resident records, and failure to provide scheduled activities as noted on the activity calendar.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure disclosure statements included the name of the facility and licensee after change in ownership. |
| Facility failed to maintain a current listing of staff with valid first aid or CPR certification. |
| Facility failed to have admission agreements with residents in records after change in ownership. |
| Facility failed to provide the scheduled activity noted on the activity calendar. |
Report Facts
Number of residents present: 30
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Inspector conducting the monitoring visit |
| Staff #4 | Acknowledged issues with disclosure statements, certification postings, and resident records | |
| Staff #5 | Acknowledged issues with disclosure statements, certification postings, and resident records |
Inspection Report
Original Licensing
Deficiencies: 2
Jul 10, 2024
Visit Reason
The inspection was an initial licensing inspection conducted to evaluate compliance with applicable standards and laws for Commonwealth Senior Living at the Devonshire.
Findings
The inspection found non-compliance related to maintenance issues including torn window and patio door screens, dirty carpets, and presence of wasp nests on the exterior of the building. The facility was cited for failure to maintain the building in good repair and to keep it free of infestations.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish, including torn patio door screen, torn window screens, and dirty carpets. |
| Facility failed to ensure the building was kept free of infestations of insects and vermin, evidenced by several wasp nests with live wasp activity on the building's rear exterior. |
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