Facility Evaluation Report

Licensing Program Analysts (LPAs) Florio and Cuadra arrived unannounced to conduct the required 1-year annual inspection. LPAs met with LIsa DiBartolo, Assistant Administrator and Alex Varshavsky, Licensee arrived shortly after. The facility has residents receiving hospice services and residents with Dementia diagnoses . LPAs observed residents were not participating in any activities.

LPAs/Licensee toured the facility inside and outside at approximate 9am: The facility is a one story building and has an approved fire clearance dated November 16, 2022 that allows for 28 non-ambulatory residents and 6 bedridden resident. Fire Extinguishers were last serviced February 2024. Facility has a centralized fire alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last maintenance was conducted 2/14/24. Facility has a locked perimeter. Smoke detectors, sprinklers, carbon monoxide detectors were present throughout the facility. LPAs pulled emergency alerts in residents rooms and staff responded in a timely manner. Fire panel was last inspected 02/14/2024. Last disaster drill was conducted on 03/14/24. Facility had sufficient perishable and non-perishable food. Annual fees are current.

At approximate 9:30am LPAs/Licensee observed in communal area and in one resident bedroom, there was a wheel chair stored in front of sliding glass door, obstructing the exit. This poses an immediate safety risk to residents in care. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today.

At approximate 9:45am LPAs/Licensee observed auditory emergency signal system not working or lacking in 4 out of the 12 client bedrooms inspected. Also, auditory alarms on several resident bedroom sliding glass door exits were not activated.