Routine inspection·April 29, 2025

At approximately 2:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and quarterly non-compliance visit and was greeted by facility Staff. Mary Grace Defeo, Administrator was contacted via telephone and arrived at approximately 3:00 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care (one was away in the hospital during today's inspection). Facility has a Dementia Care Plan, a Hospice waiver for two (2), and is approved for 4 non-ambulatory residents, two (2) of which may be bedridden. Facility currently has three (3) Hospice residents in care. Administrator will submit a request for a Hospice exception to the Department for the third resident.. Facility is currently on Non-Compliance for the following reasons: Lack of Liability Insurance in the proper amounts. Lack of proper funds to properly maintain facility. LPA will return to RO to conduct further file review and consult with Licensing Program Manager (LPM) regarding the facility's non-compliance status and will follow up with facility at a later date. At approximately 2:20 PM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. 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. Continued on LIC809C... Continued from LIC809... LPA observed a fold-up roll away bed in the master bedroom walk-in closet. Staff and Administrator state that it is used for their 24 hour staff who sleep in the living room when on shift. LPA informed Administrator that staff shall not sleep in a common area of the facility or any room not approved on a fire clearance for staff sleeping quarters in order to operate in compliance with regulation. Cabinets containing cleaning supplies and other items that could pose a risk were observed locked. 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 inspected one unlocked shed in the backyard which contained care equipment, holiday decorations, and personal items. LPA observed residents in their bedrooms watching TV. Facility has an internet access device designated for resident use and internet access. Facility telephone was tested an operational during inspection. Facility's fire extinguisher was observed fully charged and was last inspected 02/2025. Smoke and carbon monoxide detectors were tested and operational during inspection. LPA will return to RO to conduct further file review and consult with LPM. LPA will return at a later date to complete inspection and conduct file review and review medications and medication records. LPA may issue citations at that time. Facility does not handle P&I cash resources for residents. No deficiencies cited during today's inspection. Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Appeal rights provided.