Inspection Reports for Daybreak Village Senior Living Community
3056 CHEROKEE STREET, KENNESAW, GA, 30144
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 6, 2025, found deficiencies related to staff qualifications, training, background checks, and aging in place requirements including fire drill performance and notifications. Earlier inspections showed similar issues with staff certifications, training hours, criminal background checks, and fire safety compliance. Prior complaint investigations were mostly unsubstantiated except for a substantiated case in July 2020 involving failure to refer a resident for appropriate services when their condition changed, and an August 2019 finding related to inadequate care and supervision after a resident eloped and was injured. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The pattern of deficiencies in staff training and safety requirements has persisted over time without clear improvement.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
1 residents
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 6
Date: May 6, 2025
Visit Reason
The purpose of this visit was to conduct a follow-up visit to verify correction of previous deficiencies.
Findings
The facility failed to designate qualified staff to act on behalf of the administrator or on-site manager during their absence, lacked evidence of current certifications in emergency first aid and CPR for staff, did not ensure all direct care staff had at least sixteen hours of training per year, failed to obtain satisfactory criminal background checks for certain employees, and did not meet requirements related to aging in place exceptions including fire drill performance, staffing, and notification to the local fire department.
Deficiencies (6)
Failed to designate qualified staff as responsible to act on behalf of the administrator or on-site manager during their absence.
Lack of evidence of current certification in emergency first aid for staff.
Lack of evidence of current certification in cardiopulmonary resuscitation where training required return demonstration.
Direct care staff, including administrator or on-site manager, did not have at least sixteen hours of training per year.
Failed to obtain satisfactory criminal history background checks for certain employees prior to employment.
Failed to meet aging in place exceptions requirements including fire drill performance, staffing, and notification to local fire department.
Report Facts
Number of staff without satisfactory background checks: 4
Aging in place exceptions allowed non-ambulatory residents: 3
Fire drill evacuation time: 13
Minimum fire drills per month: 1
Minimum training hours per year: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in background check deficiency and stated lack of access to g-chex roster. | |
| Staff B | Named in background check deficiency. | |
| Staff C | Named in background check deficiency. | |
| Staff D | Named in background check deficiency. | |
| Staff E | Stated not knowing who was in charge during management absence. | |
| Staff F | Stated being home sick during management absence. |
Inspection Report
Complaint Investigation
Census: 1
Deficiencies: 5
Date: Sep 18, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00249295 and conduct a compliance inspection at Daybreak Village Senior Living Community.
Complaint Details
The visit was complaint-related, investigating intake #GA00249295. The complaint involved concerns about staff qualifications, training, background checks, and fire safety compliance.
Findings
The facility failed to ensure staff had current certifications in emergency first aid and cardiopulmonary resuscitation, adequate annual training hours, and satisfactory criminal background checks. Additionally, the facility did not meet requirements for fire drills frequency and notification to the local fire department regarding a non-ambulatory resident.
Deficiencies (5)
Staff A and Staff B lacked evidence of current certification in emergency first aid.
Staff A and Staff B lacked evidence of current certification in cardiopulmonary resuscitation.
Staff B and Staff C lacked evidence of at least sixteen hours of training per year for 2023.
Staff A, Staff B, and Staff C lacked documentation of a satisfactory fingerprint background check.
Facility failed to increase fire drills to a minimum of one per month covering all shifts and failed to notify the local fire department in writing of the resident's change to aging in place status.
Report Facts
Number of non-ambulatory residents: 1
Fire drills conducted: 4
Required training hours: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiencies for expired first aid and CPR certifications, missing fingerprint background check, and insufficient training hours. | |
| Staff B | Named in deficiencies for expired first aid and CPR certifications, missing fingerprint background check, and insufficient training hours. | |
| Staff C | Named in deficiencies for missing fingerprint background check and insufficient training hours. | |
| Staff D | Interviewed staff who confirmed lack of documentation for certifications, training, background checks, and fire safety compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 13, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240596.
Complaint Details
Investigation of intake #GA00240596 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA002400001. An on-site visit was made to the facility on 2023-10-31, and the investigation was completed on 2023-11-03.
Complaint Details
Investigation of intake #GA002400001 was conducted with no deficiencies or rules cited.
Findings
No rule was cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00232670 and conduct the compliance inspection.
Complaint Details
Investigation of intake GA00232670 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 3, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA220533. The inspection started on 2022-01-25 and was completed on 2022-02-03.
Complaint Details
Investigation of intake #GA220533 with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 1, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00216982, which started on 2021-09-09 and was completed on 2021-10-01.
Complaint Details
Investigation of intake #GA00216982 was completed with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 31, 2021
Visit Reason
The inspection was conducted to investigate intake #GA00211894 and #GA00213245 and to conduct a compliance inspection.
Complaint Details
Investigation of intake #GA00211894 and #GA00213245; no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 22, 2020
Visit Reason
The purpose of this survey was to investigate intake #GA00207474, which started on 2020-08-14 and was completed on 2020-09-22.
Complaint Details
Investigation of intake #GA00207474 found no rules violations.
Findings
No rules violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 27, 2020
Visit Reason
The purpose of this inspection was to investigate intake GA00205054.
Complaint Details
Investigation began on 2020-06-11 and was completed on 2020-07-27. No rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 2, 2020
Visit Reason
The purpose of this investigation was to investigate complaint #GA00203862, which began on 2020-05-06 and was completed on 2020-07-02.
Complaint Details
Investigation was complaint-driven (#GA00203862) and substantiated by findings that the facility did not refer Resident #1 for appropriate services despite decline and hospice care.
Findings
The facility failed to refer a resident for appropriate services when the resident's condition changed, specifically for Resident #1 who had declined and received hospice services. Interviews and record reviews confirmed the resident's decline and hospice care, but the resident was not listed on the facility census at the time of the investigation.
Deficiencies (1)
Facility failed to refer resident for appropriate services as required when the resident's condition changed.
Report Facts
Investigation start date: May 6, 2020
Investigation completion date: Jul 2, 2020
Resident admission date: Aug 10, 2016
Hospice initial assessment date: Jan 23, 2017
Hospice service duration: 2
Activities of Daily Living (ADLs) needing assistance: 6
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess infection control process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 25, 2020
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate multiple complaint intakes (#GA 00202782, GA00202961, GA00202941, GA00203331, GA00203740).
Complaint Details
The inspection was triggered by multiple complaint intakes (#GA 00202782, GA00202961, GA00202941, GA00203331, GA00203740).
Findings
The facility failed to obtain satisfactory criminal records checks for 3 of 6 sampled staff, admitted and retained residents who were not ambulatory or capable of self-preservation with minimal assistance for 4 of 5 sampled residents, and failed to ensure 3 of 6 sampled residents were free from physical restraints, including blocked wheelchairs and bedrails.
Deficiencies (3)
Failed to obtain a satisfactory criminal records check prior to employment for 3 of 6 sampled staff (Staff C, Staff D, Staff E).
Admitted and retained residents who were not ambulatory or capable of self-preservation with minimal assistance for 4 of 5 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4).
Failed to ensure residents were free from physical restraints for 3 of 6 sampled residents (Resident #5, Resident #6, Resident #7), including blocked wheelchair and bedrails.
Report Facts
Number of sampled staff without criminal records check: 3
Number of sampled residents not ambulatory or capable of self-preservation: 4
Number of sampled residents restrained: 3
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 4, 2019
Visit Reason
The purpose of this visit was to conduct a follow up inspection to the 8/7/19 investigation of intake #GA00198406.
Findings
There were no rule violations cited as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Date: Aug 7, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00198406 related to a resident elopement incident.
Complaint Details
The investigation was triggered by intake #GA00198406 regarding Resident #1 eloping from the facility on 7/22/19, walking approximately two blocks, sustaining a head laceration and fractured hip. The resident had dementia and family had refused memory care services. The facility's response and supervision were inadequate, with unlocked doors and delayed discovery of the resident's absence.
Findings
The facility failed to ensure adequate care and services for Resident #1 who eloped from the facility, resulting in injury. The assisted living area entrance door was unsecured, and Resident #1 was found injured off-site after leaving the facility unescorted.
Deficiencies (1)
Facility failed to ensure each resident received adequate and appropriate care and services in compliance with federal and state law, evidenced by Resident #1's elopement and injury.
Report Facts
Facility census: 51
Assisted living residents: 33
Memory care unit residents: 18
Staff on duty: 4
Temperature: 96
Date of Resident #1 admission to MCU: Aug 6, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Interviewed staff who received call about Resident #1 eloping and provided details about the incident | |
| Staff A | Interviewed staff who described Resident #1's exit from the building and timeline of discovery | |
| Staff B | Interviewed staff who last saw Resident #1 after lunch and described resident's behavior | |
| BB | Interviewed staff who was notified by police and met Resident #1 at hospital |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 26, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00195341.
Complaint Details
Investigation of intake #GA00195341 with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 25, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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