Facility Evaluation Report

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to continue a Required 1 Year visit and met with Administrator, Jolly Carungcong, and Executive Director, Frank Nola. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 41 non-ambulatory and 6 bedridden residents for a total capacity of 47 residents. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 21 Residents in care and 7 staff members on-site.

At approximately 9:30AM, LPA and LPM reviewed staff files and client medication. Staff files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. Administrator's Certificate for Jolly Carongcung (7027194740) current with expiration date of 01/06/2026.

LPA requested the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)

Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of 10/18/2024.

Exit interview conducted. Copy of report discussed and provided to Administrator and Executive Director. Signature on form confirms receipt of documents.