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f <br /> 3 <br /> a STATf a <br /> NC DEPARTMENT OF ROY COOPER - Governor <br /> HEALTH AND MANDY COHEN,MD,MPH • Secretary <br /> HUMAN SERVICES JOYCE MASSEY-SMITH,MPA - <br /> •`@""""°"• Director,Division of Aging and Adult Services <br /> DIVISION OF AGING AND ADULT SERVICES <br /> OFFICE OF THE STATE LONG-TERM CARE OMBUDSMAN <br /> Date of Attestation <br /> January 3111, 2023 <br /> Statement of Attestation <br /> CAC Member Name: Shade Little <br /> This document verifies that Shade Little, a new member of the Orange County Nursing Home <br /> Community Advisory Committee has completed the "HB248-Final Rule Update% Community <br /> Advisory Committee update training authorized by the Office of the State Lonca-Term Care <br /> Ombudsman conducted in Orange. NC on 113112023. <br /> Your signature below indicates your acknowledgement to abide by HB 248, the Final Rule, and the <br /> Policies and Procedures of the Long-Term Care Ombudsman Program. It also acknowledges your <br /> agreement to follow the Community Advisory Committee processes: <br /> ❖ Certification and Designation Process <br /> ❖ Appointment Process <br /> ❖ Suspension of Designation Process <br /> ❖ Reinstatement of Designation Process <br /> ❖ Removal of Designation Process <br /> You may contact Victor Orija, State Long-Term Care Ombudsman at(919) 855-3426, if you require <br /> additional information. <br /> CAC Member: Shade Little Regional Ombudsman: <br /> Date: 1 *4- 2 � 3 Date: Z� <br /> Address 2. �OL11� <br /> State Ombudsman: <br /> City/State/ZIP:C� � Date: <br /> WWW.NCDHHS.GOV <br /> TEL 919-855-3400-FAx 919-733-0443 <br /> LOCATION:693 PALMER DRIVE•TAYLOR HALL-RALEIGH,NC 27603 <br /> MAILING ADDRESS: 2101 MAIL SERVICE CENTER-RALEIGH,NC 27699-2101 <br /> AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER <br /> Created With Tiny Scanner <br />