Facility Evaluation Report

At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual continuation inspection and quarterly non-compliance visit and was greeted by facility Staff. Mary Grace Defeo, Administrator was contacted via telephone and arrived at approximately 10:45 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care (one was away at 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 and has a Department approved Hospice exception for the third Hospice 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.

Facility currently has proof of liability insurance in the proper amounts. LPA will return to RO to conduct further file review and consult with Licensing Program Manager (LPM) regarding the results of the solvency audit conducted. Areas of concern noted during initial annual inspection visit conducted on 04/29/2025 have been resolved. Facility conducts quarterly disaster drills with the last one conducted 04/2025. Facility's emergency disaster plan was last updated 03/2025.