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Source: VA State Licensing Agency
Type of inspection: ?Monitoring? Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/12/2026, 10:20 a.m. to 1:50 p.m. 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 records and 2 observations only Number of staff records reviewed: 3 and 1 interview Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017or by email at Jacquelyn.Kabiri@dss.virginia.gov
Based on direct observation and staff interview, the facility failed to ensure that a staff person was available to lead the activity. Evidence: 1. On 01/12/2026, the LI reviewed the posted activity schedule, which listed Bingo at 11:00 a.m., Arts & Crafts at 1:30 p.m., and Exercise or Dancing at 3:00 p.m. 2. At 11:00 a.m., the LI observed residents sitting in the living room TV area with no activity in progress. Residents were not participating in or gathered for the scheduled activity. 3. Staff 1 acknowledged LI?s observations.
Based on direct observation and staff interview, the facility failed to ensure that menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents. Evidence: 1. On 01/12/2026, the LI observed a monthly menu posted on a corkboard in the first-floor dining area that did not include a date, month, or year. 2. Staff 1 acknowledged the LI?s findings. 3. Photo evidence obtained.
Based on direct observation, the facility failed to ensure that the interior of all buildings was maintained in good repair and kept clean. Evidence: 1. On 01/12/2026, the licensing inspector (LI) made the following observations during the inspection: a. Resident 2?s bedroom door had two large circular areas where the paint was peeling. b. Resident 5?s bedroom window blinds were broken and bent on the right side. c. Resident 3?s bedroom carpet had 15 small, circular dark red spots near the bed and three medium-sized areas where the carpet color was missing. d. The stairway leading to the basement was worn, with several black spots on four steps. The final step at the bottom was torn and had a large yellow-brown stain in the corner. 2. Photo evidence obtained.
Based on direct observation, the facility failed to ensure all operable windows were effectively screened. Evidence: 1. Rooms for residents 4 and 5 had windows that were not effectively screened. 2. Photo evidence taken.
Type of inspection: ?Renewal? Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/15/2025, 9:45 a.m. to 3:45 p.m. 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 (plus 2 additional partial record reviews) Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Medication administration, cards, exercise, lunch. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017or by email at Jacquelyn.Kabiri@dss.virginia.gov
Based on observations and staff interview, the facility failed to ensure all operable windows were effectively screened. Evidence: 1. On 1/15/2025, the licensing inspector (LI) observed resident 1, 5, and 6?s bedroom windows unscreened. 2. During the facility tour on 1/15/2025, LI observed the downstairs living room windows were unscreened. 3. Staff 1 confirmed the inspection findings of unscreened windows.
Based on observations and staff interview, the facility failed to ensure that all furnishings were kept in good repair and condition. Evidence: 1. On 1/15/2025, LI observed a black recliner chair with what appeared to be spots and stains on the upholstery in resident 6?s room. 2. LI observed resident 1?s room with broken mini blinds. 3. Staff 1 confirmed the LI?s findings of broken miniblinds and stained chair upholstery. 4. Photo evidence taken.
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/04/2024, 09:00-12:30. 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: 7 Number of resident records reviewed: 3 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Toured the facility, observed medication administration, and checked the medication cart for prescribed medications. LI also observed residents participating in activity programs and eating breakfast and lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. 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 , Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.kabiri@dss.virginia.gov
Based on record review, the facility's resident orientation form was not signed by the resident. Evidence: The resident orientation information form was not signed by the resident 1.
Based on record review and staff interview, the facility?s dietary oversight form did not contain a dietary certification statement. Evidence: Staff 1 provided a record of on-site dietary oversight dated 4/14/2024, which did not include certification that the requirements of the regulations were met.
Based on facility record review and staff interview, the facility failed to ensure the disclosure statement was on the form developed by the Virginia Department of Social Services (VDSS). Evidence: 1. Staff 2 provided the Disclosure Statement to the licensing inspector. 2. The Disclosure statement form was edited. The footers on all pages and the formatting for the entire document had been adjusted. 3. Staff 2 confirmed that they had modified the original department form.
An unannounced renewal inspection was conducted on 2/28/23. At the time of entrance, eight resident s were in care. A meal, medication administration, and an activity were observed. Building and grounds were inspected and records were reviewed. The sample size consists of four resident records and three staff records. The violation was discussed and an exit meeting was held. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Based on record review, the facility failed to ensure that each resident with a special diet, receives diet oversight every six months, by a dietitian or nutritionist. Evidence: Resident #3's record was reviewed during the inspection. Resident #3's physical examination report, dated 9/25/18, states that he needs a pureed diet. The most recent dietitian oversight note, included in Resident #3's record, was completed in July 2022. Dietitian documentation indicated that a visit was made to the facility in October 2022, but no documentation was observed to indicate that Resident #3 had diet oversight within the past six months.
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