Avalon House on Dolley Madison

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/31/2025 (8:00 AM - 10:00 AM) Number of residents present at the facility at the beginning of the inspection: Seven The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Two Number of interviews conducted with staff: Two Observations by licensing inspector: Breakfast, medication administration The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/6/24 (8:30 AM - 12:10 PM). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: Seven The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Two Number of interviews conducted with residents: One Number of interviews conducted with staff: Two Observations by licensing inspector: Breakfast, medication administration, activity An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.

Date of Inspection: August 23, 2023 Type of Inspection: Monitoring Inspection Census: 7 Number of records reviewed and interviews conducted- 5 records, 3 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed resident participating in games and flower arranging. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov.

Type of inspection: Renewal An unannounced renewal inspection was conducted on 7/12/2022. At the time of entrance eight residents were in care. Sample size consisted of four resident records and two staff records. Resident and staff records and other documentation were reviewed. Virginia State Police background checks reviewed for all new staff hired since the previous inspection. Residents were observed eating and engaging in activities. Medication administration was reviewed. An exit meeting was conducted to review the inspection findings. The information gathered and reviewed today were found to be in compliance with Standards and no violations were issued today. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tammy Pruitt, Licensing Inspector at (703) 314-0604 or by email at tammy.pruitt@dss.virginia.gov A copy of this document will be sent to the applicant for signature.

A renewal inspection was initiated on 8/16/2021 and concluded on 8/17/2021. The Administrator was contacted by telephone to initiate the inspection and reported that the current census was 15. The Licensing Inspector (LI) emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The LI reviewed two resident records, two staff records, staff schedules, health care oversight, fire and emergency drills, Fire Inspection, Health Inspection, activity calendar, menu and the most recent dietary oversight submitted by the facility to ensure documentation was complete. Background Checks of all staff hired since the previous inspection were reviewed. The LI conducted the on-site portion of the inspection on 8/17/2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.

This inspection conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A mandated monitoring inspection initiated on 5/26/2021 and concluded on 5/26/2021. The Administrator contacted by email to initiate the inspection. The Administrator reported that the current census was seven. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed five resident records, five staff records, local fire and health inspection and other documentation submitted by the facility to ensure documentation complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations issued. Thank you for your cooperation and if you have any questions please call 703-314-0604 or contact me via e-mail at tammy.pruitt@dss.virginia.gov.