Facility Evaluation Report

At approximately 2:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and quarterly non-compliance visit and was greeted by facility Staff. Mary Grace Defeo, Administrator was contacted via telephone and arrived at approximately 3:00 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care (one was away in the hospital during today's inspection). Facility has a Dementia Care Plan, a Hospice waiver for two (2), and is approved for 4 non-ambulatory residents, two (2) of which may be bedridden. Facility currently has three (3) Hospice residents in care. Administrator will submit a request for a Hospice exception to the Department for the third resident..

Facility is currently on Non-Compliance for the following reasons:

Lack of Liability Insurance in the proper amounts.

Lack of proper funds to properly maintain facility.

LPA will return to RO to conduct further file review and consult with Licensing Program Manager (LPM) regarding the facility's non-compliance status and will follow up with facility at a later date.

At approximately 2:20 PM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. 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 Title 22 regulations.