Facility Evaluation Report

Licensing Program Analysts (LPAs) Contreras and Cuadra arrived unannounced to conduct the required 1-year annual inspection. LPAs met with Lisa DiBartolo, Administrative Assistant. The facility has residents receiving hospice services and residents with Dementia diagnoses. Annual fees are current. Required postings were observed. Contact information was reviewed.

Upon arrival, LPAs/staff noticed one gallon of detergent and 11 bottles of cleansers sitting on reception area accessible to residents. There were three staff around the reception area (technical advisory issued). LPAs/staff toured the facility inside and outside at approximate 9:30am: 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 12/19/24. Facility has a locked perimeter. Smoke detectors, sprinklers, carbon monoxide detectors were present throughout the facility. Fire panel was last inspected 12/19/2024. Last disaster drill was conducted on February 2025.

The facility is a one story building and has an approved fire clearance dated September 26, 2024 that allows for 34 ambulatory and 28 non-ambulatory residents and no bedridden resident. However, during records review two (R1 and R2) out nine residents have a bedridden status and are occupying room #1 (R1) and room #19 (R2), which are not cleared by the Fire Department as bedridden rooms. Licensee is operating outside the limitation of the license by accepting a bedridden resident in a non-ambulatory room. LPA/staff discussed the issue with R1 and R2 to provide the option to submit a request to the Fire Marshall to assess bedrooms to grant fire clearance. According to the Administrative Assistant, R1 and R2 are not bedridden and they have reached out during LPAs vitis to both physicians to obtain an updated physician's report (LIC602). During the visit, LPA spoke with R1 and R2 who expressed that they are not fully bedridden and they are in agreement to obtain an updated medical assessment. Fire Extinguishers were last serviced February 2024. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today.