Facility Evaluation Report

At approximately 9:45 AM, Licensing Program Analysts (LPAs) Julie Florio and Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and were greeted by Staff. Designated Responsible Party (DRP), Frank Nola, was contacted and arrived at approximately 10:20 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with 19 residents in care. Facility has a Dementia Care Plan, is approved for 11 non-ambulatory residents, bedridden residents on first floor only, and has a Hospice waiver for 5. Facility currently has one (1) Hospice resident in care.

At approximately 10:40 AM, LPAs initiated a tour of the facility with DRP and observed the following: Facility is a two story converted convent, was a comfortable temperature, and passageways were free from obstructions. LPAs observed an evacuation chair at each stairwell for emergency prepairdness. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs 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 Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPAs observed a menu posted throughout the facility, and facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency Food and water supply. However, LPAs observed at least three instances of expired food and several instances of unlabeled opened or unsealed food items throughout facility freezers and refrigerators, (see LIC809D). Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPAs observed two (2) locked sheds in the backyard which LPAs inspected and observed the contents to consist of PPE supplies, extra resident care equipment, holiday decorations, chemicals and tools.