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Source: VA State Licensing Agency
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/23/2025, 9:45am -11:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/11/2025 regarding allegations in the area(s) of: resident care and related services, and building and grounds 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed posted menu, resident bedroom and bathroom, and the facility food supply. Additional Comments/Discussion: Licensing inspector interviewed resident at their day program. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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 Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov
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: 11/5/25, 10:17am-12pm 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: 1 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 residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed all required facility postings, a medication pass, and the facility food supply. 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 Tyia Venable, Licensing Inspector at (804)393-2157 or by email at tyia.venable2@dss.virginia.gov
Based on a review of staff records, the facility did not ensure that each staff person on or within seven days prior to the first day of work at the facility submitted results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form. Evidence: 1. Staff 1?s (date of hire:8/18/25) record contained a tuberculosis assessment dated 10/28/25. 2. When asked Staff 2 stated the tuberculosis assessment was not completed prior to or within seven days of Staff 1?s date of hire.
Based on a review of the resident records, the facility did not ensure the rights and responsibilities of residents was reviewed annually with each resident. Evidence: 1. Resident 2?s (admit date: 7/1/24) record contained rights and responsibilities of residents dated 7/1/24. 2. Resident 2?s record did not contain documented evidence of an annual review of resident?s rights and responsibilities. 3. When asked Staff 2 stated there was no documented evidence of an annual review of resident?s rights and responsibilities with Resident 2
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: 6/11/2025 10am-11:15am, 6/18/2025 7:12am-7:38am 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: 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: 2 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 postings and documentation were observed Additional Comments/Discussion: n/a 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 Tyia Venable, Licensing Inspector at (804) 393-2157 or by email at tyia.venable2@dss.virginia.gov
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: On 11/27/2023 at 12:36p.m. On 12/14/2023 Approximate time 9:41a.m-12:20p.m. On 12/29/2023 Approximate time 6:30a.m-7:30a.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: 10 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 2 Number of interviews conducted with residents:7 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication administration pass was observed. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov
Based on the review of facility records and staff interview the facility failed to ensure that within the 30 days preceding admission, that a resident?s physical examination by an independent physician contained all the required elements. Evidence: Resident #1-Documented date of admission 02/01/2023 Resident #4-Documented date of admission 03/01/2023 12/14/2023: While on site the facility the Administrator stated during the interview that the health and physical examination documentation for resident #s 1 and 4, that were in the resident?s records is used as the health and physical examination documentation required upon admission. The residents? documents did not include: the residents? address, and telephone number, height, weight, and blood pressure; significant medical history; general physical condition, including a systems review as is medically indicated; any diagnosis or significant problems; any known allergies and description of the person's reactions; any recommendations for care including medication, diet, and therapy; results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it; a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; a statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter; a statement that specifies whether the individual is or is not capable of self- administering medication.
Based on the review of facility records and staff interview the facility failed to ensure that in a facility licensed only for residential living care, all direct care staff attend at least 14 hours of training annually. Evidence: Staff #1-Documented date of hire 05/19/2008 The review of facility records with the facility Administrator on 12/14/2023 revealed that facility staff #1 only had 12 of the 14 hours of required annual training.
Type of inspection: Monitoring Date(s) of inspection: 04/25/2023 Time the licensing inspector was on-site at the facility for each day of the inspection: 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: 10. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 04. Number of staff records reviewed: 01. Number of interviews conducted with residents: 01. Number of interviews conducted with staff: 01. Observations by licensing inspector: buildings and ground and medication administration observation Additional Comments/Discussion: N/A 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, Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov
Based upon the record review, the facility failed to have a physical examination on file within a 30 day time frame preceding the resident?s admission date. EVIDENCE: Resident record #3 failed to have a physical examination on file with the facility.
Type of inspection: Monitoring Technical Assistance Provided: 22VAC40-73-100. Infection control - Reference VDSS website concerning the Division updates concerning any new protocol, notices, trainings, as well as documents and procedures. Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: Dates: 3/28/2022 Time : 1:47 p.m. to 2:50p.m. and 3:-29-2022 Time: 12:35 p.m. to 1:08 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: 09 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 02 Number of staff records reviewed: 02 Number of interviews conducted with residents: Interviews conducted during building tour. Number of interviews conducted with staff: 01 Observations by licensing inspector: Medication pass and meal observation Additional Comments/Discussion: N/A An exit meeting wasconducted 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 Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti. Colson @dss.virginia.gov
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