Viewing as: Nicole Liebb — Director of Operations
Water Castle Enrollment — demonstration report. Synthetic data only; not a filing.
Application worksheet
MTR-1001 · Northbridge Demonstration Facility · WC-SNF-300 revalidation
Section 1 — Reason for submittal
| Reason | Revalidation | Engagement scope, WC-SNF-300 |
| Existing enrolment | Yes — CCN 31-DEMO01 | PECOS snapshot, p. 2 |
Section 2 — Identifying information
| Legal business name | Northbridge Demonstration Facility LLC | IRS CP-575, p. 1 |
| EIN | 00-DEMO001 | IRS CP-575, p. 1 |
| NPI | 80-DEMO-0001 | NPPES confirmation, p. 1 |
| State licence | NJ-LTC-DEMO-118, expires 2026-05-31 — expired | State licence copy, p. 1 |
Section 3 — Final adverse legal actions
| Civil money penalty | DEMO-CMP-2019-031, NJ DOH, 2019-08-20 — resolved and disclosed | Final order, complete copy |
| Suppression check | None suppressed — resolved items are still disclosed | Specialist checklist |
Section 4 — Practice location, records storage, banking
| Practice location | Lakeside, NJ — 120 beds | Licence, p. 1 |
| Records storage | On site + vault (simulated) | Intake step 7 |
| EFT account | …DEMO-4821 — voided check outstanding | Vault register |
Section 5 — Organizations with ownership or control
| Levy Family Legacy Trust | 10.00% direct — all trustees disclosed | Operating agreement, §3.1 |
| Clearbrook Management Group LLC | Management company — ADP | Management agreement (copy outstanding) |
| Lakeside Property Associates LLC | Lessor, 100.00% of real property — ADP | Lease, p. 1 |
Section 6 — Individuals with ownership or control
| Miriam Levy | 60.00% direct; authorized official | Operating agreement, §3.1 |
| Hector M. Villanueva | 30.00% direct | Operating agreement, §3.1 |
| Grace N. Adeyemi, NHA | Administrator | Payroll register, p. 1 |
| Dr. Samuel Ostrowski, MD | Medical Director (contract) | Medical director agreement |
| Yuki Tanaka, RN | UNKNOWN — DON not yet on roster | not sourced |
Section 8 — Billing agency
| Billing agency used | No | Intake step 6 |
| Water Castle role | Authorized surrogate for preparation and submission only | Engagement agreement |
Section 13 — Contact person
| Contact | Tova Grunfeld, Office Manager | Intake step 1 |
| Case owner | Nicole Liebb, Director of Operations | Matter record |
Attachment 1 — Additional owners and managing employees
| Rosa Levy | Trustee of the 10.00% trust | Trust deed, p. 4 |
| Ephraim Levy | Trustee of the 10.00% trust | Trust deed, p. 4 |
| Pinewood Community Bank, N.A. | Mortgage 3.05% — below the 5.00% floor, both values retained | Mortgage statement; balance sheet |