Complaint Investigation Report

It was alleged that the licensee does not ensure that staff are adequately trained. LPA Barutyan conducted an unannounced required annual visit on 08/07/2024 in which the facility received two (2) citations for incomplete 40 hours of initial training and 20 hours of annual continuation training. The plans of correction for the deficiencies cited on 08/07/2024 are still pending and have a due date of 09/06/2024. Based on record review and interviews, the allegation “licensee does not ensure that staff are adequately trained” is deemed SUBSTANTIATED at this time. While the allegation is substantiated, a deficiency will not be cited as the facility have open and pending plans of correction addressing personnel training. ED Willis has provided evidence of in-service training that has been conducted since 08/07/2024, and personnel are getting time allotted to complete online training at the facility.

Exit interview conducted, a copy of the report provided.