Follow-up·September 13, 2022

At approximately 2:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit, and met with Executive Director, Shannon Brown, Resident Care Director, Momo Duoa, and Nurse, Melanie Fenn. The purpose of the visit was to follow up on Change of Administrator paperwork needed for Executive Director, Shannon Brown. At this time, Momo Duoa, Resident Care Director, is the current Administrator who oversees the facility. Shannon Brown will be considered Back-Up Administrator in the event Momo Duoa, is unavailable. LPA is requesting the following documents: LIC 308 (Designation of Facility Responsibility) Active and Current Administrator Certificate First Aid Certificate Administrator Resume LIC 501 (Personnel Record) LIC 503 (Health Screening Report - personnel) Proof of TB test LIC 9182 (Criminal Record Exemption Transfer Request) LIC 508 (Criminal Record Statement) Copy of Driver's License or Passport that is not expired Facility to submit Administrator Paperwork documents to Community Care Licensing (CCL) by Friday, 9/23/22. Facility to submit Active Certificate when available. Continued on LIC-809C Continued from LIC-809 LPA conducted a walk-though of facility with Nurse, Melanie Fenn. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.