Facility Evaluation Report

On 11/15/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly visit to monitor for compliance with previously identified deficiencies. LPA Jensen met with Licensee Voica Matis and explained the purpose of today's visit.

The facility is being monitored for compliance in the following areas:

Fire Clearance with respect to retention and acceptance of bedridden clients

LPA Jensen interviewed 2 of 2 staff members who advised the Administrator is typically present at the facility from 9am-5pm Monday to Friday. The facility currently has 3 clients, 2 of which are ambulatory and 1 of which is non-ambulatory. There are no bedridden clients currently residing at the facility. LPA reviewed both staff files for the care providers present at the time of the visit and found them to be complete and in compliance. LPA Jensen reviewed 3 of 3 client files and determined them to be complete and in compliance. LPA Jensen reviewed documentation detailing a communication exchange between the Licensee and a hospice provider wherein the hospice provider has agreed to conduct staff training on postural support, patient transitioning and infection control to be scheduled after 11/20/23. LPA Jensen reviewed training records and found the training to be in compliance.

The facility was observed to be sanitary and in good repair. No deficiencies are being cited. An exit interview was conducted and a copy of this report was given.