Routine inspection·August 13, 2025

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. Continued on LIC809-C... Continued from LIC809... LPA observed a staff bedroom in the downstairs area of the facility which is missing a bedroom door. Additionally, LPA was informed that night staff also sleep on the facility couch when Licensee is away. LPA spoke with Licensee who agrees to install a bedroom door on the staff room and understands that no staff shall sleep in a common area of the facility per regulation. Cabinets containing cleaning supplies and other items that could pose a risk were observed unlocked. Licensee agrees to ensure these items are secured moving forward. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed residents resting or visiting with loved ones in their rooms or watching TV in the common area. Facility has internet service and the telephone was tested and operational during inspection. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility's fire extinguishers were observed fully charged and were last inspected 09/2024. LPA observed PPE, emergency supplies, a first aid kit, flashlights and a backup generator for emergency preparedness. DRP was unable to access resident and staff files due to Licensee being away from the facility with the keys to the filing cabinet which contains these records. LPA spoke with Licensee and explained that all facility documents and files shall be readily available at the facility and to licensing personnel upon request at all times in order to operate in compliance with regulation. LPA will return at a later date to conduct file and medication records review and follow up on the issues observed and discussed with Licensee today to ensure facility has been brought into compliance with regulation. LPA may issue citations at that time. No deficiencies cited during today's inspection. Exit interview conducted with DRP whose signature on form confirms receipt.