Complaint Investigation Report

Regarding the allegation "Licensee allowed a volunteer to perform staff duties" it was alleged Volunteer #1 (V1) performed staff duties and without supervision. Record review of the staff roster and V1’s facility file revealed V1 was listed as a volunteer and not yet 18 years old. Record review of the facility program plan revealed the job description for ‘Receptionist’ required the individual to be at least 18 years old. LPA called the facility prior to the investigation at 4:45 p.m. on 10/06/25 and V1 answered and directed LPA’s call. Interview with the administrator at 2:15 p.m. on 11/06/25 revealed V1 mainly answers phones in the reception area and does not interact directly with residents. Interviews with four (04) out of seven (07) staff revealed they have seen V1 perform staff duties without supervision. Interviews with four (04) out of eleven (11) residents revealed they have seen V1 perform staff duties without supervision. Six (06) out of eleven (11) residents were unsure. Based on observations, interviews, and record review, V1 has performed receptionist duties without sufficient supervision. Therefore, the allegation is deemed SUBSTANTIATED at this time.

Exit interview conducted. Appeal rights discussed. Copy of report provided.