Facility Evaluation Report

At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by staff. Norbert Sacro, Licensee/Administrator was contacted via telephone and was unable to come to the facility for today's inspection. Licensee/Administrator gave LPA permission to proceed with the inspection with Lino Caramat, staff member and Designated Responsible Party (DRP). Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. Facility has a Dementia Care Plan and is approved for three (3) ambulatory, two (2) non-ambulatory, and one (1) bedridden resident.

At approximately 11:00 AM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices activated on all facility doors and an evacuation chair at the top of the gated stairway. Water temperatures in residents' bathrooms measured above and blow the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA spoke with Licensee who agrees to bring the facility into compliance. 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. LPA observed what appeared to be a Hospice resident and a non-ambulatory resident in the shared downstairs bedroom of the facility which is approved for non-ambulatory and a bedridden resident only. LPA spoke with Licensee who agrees to submit a Hospice waiver request immediately to the Department. Additionally, LPA informed Licensee of the need for a privacy screen of some sort for the Hospice resident and a signed agreement of understanding between the facility and both residents. Licensee agrees to bring the facility into compliance with regulation.