complaint·December 14, 2023

Allegation: Facility does not maintain accurate staff records. It was alleged that the facility listed non-staff as staff members for the purpose of obtaining Covid-19 vaccinations for them. To investigate this allegation LPAs conducted an interview with the Licensee and the Administrator and were informed that during the COVID (in 2021), facility had six (6) to seven (7) staff members working and during that time, the staff would call out, quite, etc. In addition, Licensee informed LPAs that during the COVID, staff would come and go and every new hired staff member got vaccinated, since it was a requirement at that time. Moreover, LPAs conducted an interview with two (2) staff members and both denied the allegation and reported no one, other than the facility staff member, received vaccinations. Lastly, LPAs observed former staff files in a cabinet that were archived and kept locked in the garage and current staff files were located in a kitchen cabinet and kept locked. LPAs reviewed the current facility staff schedule (LIC500) and the schedule accurately reflected who the LPAs observed working at the facility today. Allegation: Facility does not have a qualified administrator. To investigate this allegation LPAs conducted review of Administrators' certificate issued on 04/16/2021. LPAs observed the expiration date was 11/29/2023. Interview with the Administrator revealed that all required courses have been completed and all documents have been already mailed out around November 15 th , 2023. At 11:39am, LPA Panushkina contacted "Administrator Certification Unit" and confirmed that the application received and is currently being processed. Allegation: Facility housed staff in the facility garage. To investigate this allegation, LPAs observed/reviewed the facility sketch and it was noted that the garage is used as a garage not as a room. At 9:58am, during the walk through, LPAs entered the attached garage, located by the kitchen, and observed many storage boxes in the garage. According to staff, the facility has only one awake staff at night, and the garage is being used for an extra storage and emergency supply. Based on inspection, observation and interviews there is no sufficient evidence to support the allegations. Therefore, all three (3) allegations are Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.