Routine inspections were consistently clean, with no deficiencies cited in any annual or special inspections from August 19, 2021, through August 27, 2025. Several complaint investigations were unsubstantiated, including one in July 2023 that found no evidence to support allegations of neglect or visitor restrictions. The most recent report from August 27, 2025, confirmed the facility remained clean, sanitary, and in good repair with all safety measures and medication procedures properly followed. There were no fines, enforcement actions, or severe issues noted in the available reports. This record shows a stable compliance history with no significant concerns over time.
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. Safety measures, medication procedures, and facility equipment were all in proper working order. Staff and client interviews and record reviews confirmed compliance with licensing standards.
Report Facts
Capacity: 299Census: 247
Employees Mentioned
Name
Title
Context
Shelly Smart
Executive Director
Met with Licensing Program Analysts during inspection and participated in exit interview
The visit was an unannounced case management inspection conducted in response to an incident report received on 2024-09-04 involving two residents.
Findings
No deficiencies were observed or cited during the visit. Interviews and observations indicated the residents involved have a plan in place for safety and that their families are aware and supportive of their relationship.
Report Facts
Incident report date: Sep 4, 2024
Employees Mentioned
Name
Title
Context
Tiffany Holmes
Licensing Program Analyst
Conducted the unannounced case management visit
Shelly Smart
Executive Director
Facility representative met during the visit and involved in interviews
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. Safety equipment and required postings were in place, and resident and staff records were complete and properly stored.
Report Facts
Hot water temperature range: 105Hot water temperature range: 116.2Perishable food supply: 2Non-perishable food supply: 7
Employees Mentioned
Name
Title
Context
Shelly Smart
Administrator
Met with Licensing Program Analyst during inspection and participated in exit interview
Tiffany Holmes
Licensing Program Analyst
Conducted the unannounced required annual inspection
An unannounced complaint investigation was conducted following a complaint received on 03/24/2023 alleging neglect, lack of supervision resulting in injury, denial of visitors, and failure to assist with phone calls at the facility.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Records and interviews indicated the resident had a bruise with no reported pain or recall of incident, visitors were restricted due to disruptive behavior, and staff assisted with phone calls as appropriate.
Complaint Details
The complaint was unsubstantiated. Allegations included neglect/lack of supervision causing a resident's black eye, staff not allowing visitors, and staff not assisting with phone calls. Investigation included record reviews and interviews with internal and external sources, which did not support the allegations.
Report Facts
Complaint Control Number: 08-AS-20230324081605Capacity: 299Census: 245
The inspection was an unannounced required 1-year visit to evaluate the facility's compliance with licensing requirements and infection control protocols.
Findings
No deficiencies were cited or observed during the visit. The Licensing Program Analyst provided technical assistance and evaluated the facility's implementation of infection control measures including disinfection, testing surveillance, screening protocols, and use of personal protective equipment.
Employees Mentioned
Name
Title
Context
Tiffany Holmes
Licensing Program Analyst
Conducted the unannounced required 1-year visit and evaluation.
Shelly Smart
Administrator
Met with Licensing Program Analyst during the visit.
An unannounced annual required licensing inspection was conducted to verify compliance with infection control practices and other regulatory requirements.
Findings
The inspection included a facility tour and review of COVID-19 infection control plans and practices. No deficiencies were cited during the visit.
Employees Mentioned
Name
Title
Context
Shelly Smart
Health Services Administrator
Met with during the inspection and involved in the facility tour and infection control review.
Laarni Santiago
Licensing Program Analyst
Conducted the unannounced annual required licensing inspection.
Simon Jacob
Licensing Program Manager
Named in the report as Licensing Program Manager.
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