Facility Evaluation Report

Licensing Program Analysts (LPAs) Brian Balisi and Martha Arroyo conducted a Case Management - Deficiencies visit to address deficiencies observed during an unrelated complaint investigation. Entrance interview conducted.

At approximately 9:50 a.m., the LPAs conducted a physical plant tour to ensure there were no health or safety concerns. During the tour, at approximately 9:55 a.m., the LPAs observed an individual sleeping in Bedroom #1. Interviews revealed that the individual had been working evening shifts at the facility for the past three days. However, the LPAs reviewed the list of individuals associated to the facility and did not observe Staff #1 (S1) on this list. The Administrator stated that the individual had been hired to perform housekeeping duties and was unaware that fingerprint clearance was required for S1. S1 left the premises during the LPAs’ visit.

Additionally, the Administrator reported that Staff #2 (S2) is responsible for providing care and supervision to residents during the night shift. A review of S2’s personnel file revealed that their most recent first aid certification was completed in 2019, and the last documented training occurred in 2020. Administrator was not aware that S2 was still in the facility.

Interviews further revealed that four (4) residents were transported to the hospital via ambulance on 10/07/2025 and 10/08/2025. However, a review of the facility’s records showed that incident reports were not submitted to the Department within the required seven (7) days of the occurrences, as mandated by reporting regulations. Administrator provided reports for (2) residents and was reminded to provide the other (2) reports , but they are still pending.