Facility Evaluation Report

At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Annual Continuation inspection and was greeted by Norbert Sacro, Licensee/Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care.

At approximately 10:30 AM, LPA conducted a walk through of the facility with Licensee/Administrator to follow up on areas of concern noted during previous annual inspection visit dated 08/13/2025. LPA observed the following: Licensee placed a hot water warning sign above the faucet where the water temperature tested above the allowable range of 105 to 120 degrees Fahrenheit bringing the facility into compliance with Title 22 regulations. Licensee installed a bedroom door on the staff bedroom bringing the facility into compliance with regulation. Licensee placed a privacy screen in the shared resident bedroom and had each resident sign an addendum to their admissions agreement bringing the facility into compliance with regulation. Licensee installed locks on the doors and cabinets where items which pose a risk to residents in care are stored bringing the facility into compliance with regulation.

At approximately 11:15 AM, LPA conducted file review. Three (3) staff files were reviewed and each contained the required documents per regulation. All staff files reviewed contained proof of current First Aid training. Two (2) of three (3) staff files reviewed were deficient in all of the required annual medication training, (see LIC809D). Four (4) of four (4) resident files reviewed each contained all the required documentation per regulation.