Inspection Report
Annual Inspection
Deficiencies: 0
Nov 26, 2025
Visit Reason
Annual Licensure Survey to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The Villas at St. James Breese was found to be in compliance with the applicable assisted living regulations during the annual licensure survey.
Inspection Report
Annual Inspection
Deficiencies: 1
Nov 22, 2024
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with state regulations.
Findings
The facility failed to conduct a complete employee orientation within 10 days after the date of hire for two direct care staff members, violating Section 295.3020 regarding Employee Orientation and Ongoing Training.
Severity Breakdown
Type 3 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete required employee orientation within 10 days after the starting date of employment for two direct care staff. | Type 3 Violation |
Report Facts
Number of direct care staff with incomplete orientation: 2
Orientation completion timeframe: 10
Orientation completion timeframe: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Resident Assistant | Hired 6/21/24; failed to complete required orientation within 10 and 30 days. |
| E5 | Resident Assistant | Hired 7/25/24; failed to complete required orientation within 10 and 30 days. |
| E1 | Executive Director | Confirmed facility could not present evidence of orientation completion for E4 and E5. |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 1
Nov 22, 2024
Visit Reason
The document is a Statement of Correction submitted as evidence of compliance following an Annual Survey conducted at The Villas at St. James on 2024-11-22.
Findings
The facility was found deficient in employee orientation and ongoing training requirements, specifically failing to complete orientation within 10 and 30 days of employment. Corrective actions were completed by 2024-12-09, and quality assurance measures were implemented to prevent recurrence.
Severity Breakdown
Type 3 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete employee orientation within 10 and 30 days after the starting date of employment as required by Section 295.3020. | Type 3 Violation |
Report Facts
Residents potentially affected: 67
Orientation completion date: Dec 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Paden | Executive Director | Named as responsible for corrective actions, audit completion, and training |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 24, 2024
Visit Reason
Complaint Investigation #2448565/IL179613 was conducted to determine the validity of the allegation.
Findings
The allegation could not be substantiated and no violations were cited. The facility was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code.
Complaint Details
Complaint Investigation #2448565/IL179613: The allegation cannot be substantiated. No violations cited.
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