Routine inspection·June 10, 2025

At approximately 10:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Dorla Licausi, Executive Director. Facility is a Residential Care Facility for the Elderly (RCFE) with seventy-four (74) residents in care. Facility has both assisted living and memory care residents, with a Hospice waiver for 16 and approval for 10 bedridden residents. Facility has a delayed egress system in place and the assisted living residents utilize pendants which they wear. At approximately 11:15 AM, LPA initiated a tour of the facility with ED and observed the following: Facility is a two story building, with emergency evacuation chairs in place. Facility was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices activated and staff responded timely. 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 paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Closets containing cleaning supplies and other items that could pose a risk were 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 are outdoor shaded seating areas for activities. LPA observed residents engaged in activities in common areas. Facility has internet service and an internet access device designated for resident use. Continued on LIC809-C... Continued from LIC809C... Facility's last fire inspection was conducted 03/2025. Fire extinguishers were observed fully charged and were last inspected 08/2024. Emergency Disaster Plan was reviewed and updated 05/2024. Facility conducts monthly disaster drills with the most recent drill conducted 05/2025. Facility has a back up generator for emergency preparedness. At approximately 12:00 PM, LPA conducted file review of ten (10) staff and ten (10) resident files. All staff files reviewed contained all of the required documents, proof of training and proof of current First Aid and CPR certification. All resident files reviewed contained all the required documentation. Facility assists with coordinating medical and dental appointments as well as transportation to and from appointments when residents have the need. Medications and medication records were inspected and the logs were observed maintained in compliance with regulation. Facility does not handle P&I. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit : LIC610E - Emergency Disaster Plan (updated) Exit interview conducted with ED whose signature on form confirms receipt of documents.