Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Jul 2, 2025
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 4/16/2025, 4/23/2025, 5/27/2025, and 6/3/2025 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the inspection determined no violations with applicable standards or law. The inspection summary will be posted to the VDSS website within five business days of receipt.
Complaint Details
Complaints were related to Resident Care and Related Services. The inspection found no violations and no deficiencies were cited.
Report Facts
Number of participant records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with participants: 1
Number of interviews conducted with staff: 3
Number of observations by licensing inspector: 3
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 0
Jun 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with standards or laws based on allegations received.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly.
Complaint Details
The visit was complaint-related, but the evidence gathered did not substantiate the allegations of non-compliance.
Report Facts
Number of participant records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with participants: 0
Number of interviews conducted with staff: 1
Number of observations by licensing inspector: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the complaint investigation and inspection |
Inspection Report
Renewal
Census: 18
Deficiencies: 0
May 29, 2025
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable regulations and standards.
Findings
The inspection included a tour of the physical plant, review of resident and staff records, emergency preparedness drills, medication pass observation, and other compliance checks. The evidence gathered did not support any allegations of non-compliance with standards or law.
Report Facts
Number of participant records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with participants: 2
Number of interviews conducted with staff: 4
Inspection duration hours: 3.75
Inspection Report
Monitoring
Census: 10
Deficiencies: 4
Apr 1, 2025
Visit Reason
The inspection was a monitoring visit conducted on April 1, 2025, and April 8, 2025, to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to staff orientation and training, staff health records including criminal background checks and sworn statements, incomplete physical examinations for residents, and failure to annually review residents' rights and responsibilities. Plans of correction were submitted to address these deficiencies.
Deficiencies (4)
| Description |
|---|
| Facility did not ensure orientation and training required within first seven working days of employment. |
| Facility did not ensure personal and social data including original criminal record report and sworn disclosure statement were maintained in staff records. |
| Facility did not ensure physical examination by an independent physician within 30 days preceding admission included required statements. |
| Facility did not ensure rights and responsibilities of residents were reviewed annually and documented in staff records. |
Report Facts
Number of participants present: 10
Number of participant records reviewed: 2
Number of staff records reviewed: 2
Number of interviews with participants: 2
Number of interviews with staff: 3
Audit completion date: Apr 3, 2025
Physical exam review date: Apr 2, 2025
Number of residents with incomplete documentation: 9
Number of residents with updated physicals: 8
Plan of correction submission timeframe: 5
Review request timeframe: 15
Inspection Report
Original Licensing
Deficiencies: 0
Jan 21, 2025
Visit Reason
Initial licensing inspection of the assisted living facility to review compliance with general provisions, programs and services, buildings and grounds, emergency preparedness, and licensing process.
Findings
The inspection found no violations of applicable standards or laws. Technical assistance was provided in areas including general requirements, fire and emergency evacuation plan, emergency equipment and supplies, and doors and windows.
Report Facts
Number of interviews conducted with staff: 3
Number of participants present: 0
Number of participant records reviewed: 0
Number of staff records reviewed: 0
Inspection duration (hours and minutes): 1.67
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