Facility Evaluation Report

On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection- Infection Control visit. LPA Quiroz was greeted, and granted entry into the facility by Designated of Facility Responsibility (DOFR) Diana Ignatency and explained the nature of the visit. (DOFR) indicated Administrator Nicoleta Mogojan is currently out on vacation, scheduled to return next week. Diana Ignatrmcu identified self as Designated of Facility Responsibility. LIC 308 dated 9/20/2021 on file.

This facility is licensed to provide services to (6) six Non-Ambulatory Residents and has a hospice waiver for two (2) residents.

(AD) Nicoleta Mogojan has an Administrator Certificate with expiration date of 10/31/2023. (AD) Diana Ignatencu has an Administrator Certificate with expiration date of 11/11/2022.

On or about 1:40pm LPA Quiroz along (DOFR) Ignatencu with toured the inside and outside of facility. The staff working at facility on today's date were observed to be wearing face masks upon arrival to facility. There are six residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed three (3) residents in living room area watching television, (1) one resident visiting with Family, and (2) two residents resting in their bedrooms. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating shaded area with table and chairs for residents and visitors enjoyment. Facility has completed the LIC 808 Mitigation plan and infection control plan. CONTINUED ON NEXT PAGE...