Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Oct 31, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-22 regarding allegations in the areas of personnel and resident care and related services.
Findings
The inspection found no violations with applicable standards or laws based on the evidence gathered during the inspection.
Complaint Details
Complaint related to personnel and resident care and related services; no violations were found.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 2
Resident interviews conducted: 1
Staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Aug 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-05-28 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint investigation related to allegations received on 2025-05-28; the complaint was not substantiated.
Report Facts
Number of residents present: 37
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector who conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Aug 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-25 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint related to Resident Care and Related Services; the allegations were not substantiated.
Report Facts
Number of residents present: 37
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
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Aug 8, 2025
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 8/4/2025 and 8/14/2025 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the facility and conducted interviews with residents and staff.
Complaint Details
Complaints were related to Resident Care and Related Services. The investigation did not substantiate the allegations.
Report Facts
Number of residents present: 40
Number of resident interviews: 3
Number of staff interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Monitoring
Census: 36
Deficiencies: 0
Mar 17, 2025
Visit Reason
The inspection was a monitoring visit conducted on March 17, 2025, to review administration, administrative services, resident care, and related services at Cambridge Gardens Assisted Living.
Findings
The investigation did not support any allegations or self-reports of non-compliance with standards or law. However, violations unrelated to the complaint/self-report were identified during the inspection and are documented in the violation notice. The licensee has the opportunity to submit a plan of correction to address these violations.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 38
Deficiencies: 1
Nov 13, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards related to the development of Individualized Service Plans for residents, specifically the failure to document the need for bedrails for a resident. A violation notice was issued and the facility was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to develop an Individualized Service Plan with a description of resident needs, specifically not identifying the need for bedrails for Resident 4. |
Report Facts
Number of residents present: 38
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews with residents: 1
Number of interviews with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector conducting the renewal inspection |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Aug 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with standards or laws based on allegations received.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was conducted to review the inspection findings.
Complaint Details
The inspection was complaint related, but the allegations were not substantiated as the evidence did not support non-compliance.
Report Facts
Number of residents present: 40
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Aug 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of non-compliance at Cambridge Gardens Assisted Living.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated based on the evidence gathered.
Report Facts
Number of interviews conducted with staff: 2
Number of residents present: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector who conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Aug 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review allegations of non-compliance with standards or law at Cambridge Gardens Assisted Living.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly.
Complaint Details
The complaint investigation was not substantiated as the evidence did not support the allegations of non-compliance.
Report Facts
Number of residents present: 40
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 39
Deficiencies: 1
Nov 9, 2023
Visit Reason
The inspection was conducted as a renewal inspection to review compliance with licensing requirements and facility operations.
Findings
The inspection found that the facility staff failed to submit required tuberculosis risk assessments for two staff members, which were corrected on the day of inspection. The facility plans to complete risk assessments annually for all staff.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to submit results of a tuberculosis risk assessment documenting the absence of tuberculosis for staff members B and C. |
Report Facts
Records reviewed: 6
Interviews conducted: 4
Inspection Report
Monitoring
Census: 42
Deficiencies: 0
Aug 8, 2023
Visit Reason
The inspection was a monitoring visit to review facility operations, including administration, personnel, resident care, and compliance with regulations.
Findings
The inspector reviewed records and interviews, observed resident activities and medication administration, and examined facility policies and procedures. No complaint was related to this inspection.
Report Facts
Records reviewed: 4
Interviews conducted: 3
Inspection Report
Original Licensing
Census: 43
Deficiencies: 0
Jun 23, 2023
Visit Reason
The licensing inspector conducted an announced initial inspection of the assisted living facility.
Findings
No violations were found during the inspection. The inspector observed residents participating in activities and eating lunch, reviewed policies, procedures, resident and staff records, and conducted interviews.
Report Facts
Records reviewed: 7
Interviews conducted: 4
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