Facility Evaluation Report

At approximately 11:30 AM, Licensing Program Analysts (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Linda Mahlman, Licensee. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for one (1), is approved for fifteen (15 residents, five (5) of whom can be non-ambulatory.

At approximately 12:00 PM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. Only facility staff live on the second floor of facility and residents do not have access to the stairs. LPA observed the following required postings missing from the facility communal area: CCLD reporting poster, emergency disaster plan, current administrator certificate, and resident's personal rights. Licensee agreed to post them immediately in order to operate in compliance with regulation. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods, as well as an emergency water supply. Licensee agreed to ensure all staff and miscellaneous medications are are securely stored and maintained inaccessible to residents in care in order to operate in compliance with regulation. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed five gallon paint buckets stored in the back yard. Licensee agreed to move them into secured storage or dispose of them immediately in order to bring the facility into compliance with regulation.