Covenant Columns at Cudlipp

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/30/25 2pm to 3 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaints were received by VDSS Division of Licensing on 6/4/25 regarding allegations in the area of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: medication administration documentation, file documentation An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. However, violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@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: 3/6/25, 11:15 am to 12:15 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: 5 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: snacks, file documentation, medication storage and administration, facility repair and maintenance, staff/resident interactions, Comments: Lunch Meal - baked chicken, mixed vegetables, buttered potatoes An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Type of inspection: Renewal Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 3/5/2024 12 to 2:30 p The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 5 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Facility maintenance and cleanliness, required postings, file documentation, staff/resident interaction, medication storage, resident bedrooms 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Type of inspection: Monitoring - Mandated Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 12/18/23 10:30 a to 10:45 a The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 0 The licensing inspector completed a tour of the outside of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 (no residents in care) Number of staff records reviewed: 0 (no residents in care) Number of interviews conducted with residents: 0 (no residents in care Number of interviews conducted with staff: 1 Additional Comments/Discussion: A 60 day monitoring inspection was completed. The facility currently has no residents in care. The licensee expects that the facility will be admitting residents by late January 2024. An exit meeting was 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (name), Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.

Type of inspection: Initial, Non-Mandated Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/20/23, 10:30 a to 11:15 a The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 0 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 1 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Building and Grounds, Postings, Required Furnishings Additional Comments: New applicant, no residents in care. The inspection determined no violations with applicable standard(s) or law. A six months Conditional license will be issued. 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 Yvonne Randolph, Licensing Inspector at (x804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Type of inspection: Initial, Announced Non-Mandated attempted . Date of inspection and time the licensing inspector was on-site at the facility for the day of the inspection: 8/29/23, 10:45 a to 11:15 a The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 0 The licensing inspector completed a tour of the physical plant and room measurements. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: bedrooms, kitchen, bathrooms, living space, grounds An exit meeting will be conducted to review the inspection findings. The licensing inspec tor was not able to make a determination of compliance with applicable standard(s) or law as the building was occupied by renters. The renters had furniture, clothing and personal items throughout the home. Additional Comments/Discussion: The applicant will contact the licensing inspector in October 2023 for an additional initial inspection after the renters move out and the building is cleaned and in compliance with all applicable standards - postings, furniture, medication storage, first aid kit, bedding and linens, etc. 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 Yvonne Randolph, Licensing Inspector at (804-662-7454 or by email at Yvonne.tandolph@dss.virginia.gov