VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Gloucester Adult Day Break
5873 Fiddlers Green Road
Gloucester, VA 23061
(804) 695-9008

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Nov. 1, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Comments:

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: 11/1/23 12:00pm-2:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. (emailed) Number of participants present at the facility at the beginning of the inspection: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with participants: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector observed a meal as well as activities during the inspection. 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 Alyshia Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-230-F
Description:	Based on record review, the center failed to ensure the participant?s plan of care be signed and dated by the staff person who completed the plan and the participant, family member, or legal representative. Evidence: The Plan of Care for participant # 1 did not contain a staff signature.
Plan of Correction:	This was corrected on 11/1/23. Plan of Care was signed by Staff on date of inspection.
Standard #:	22VAC40-61-250-B
Description:	Based on review of participant records, the center failed to have a current photograph or narrative physical description of the participant. Evidence: The record for participant # 2 did not contain a picture or description.
Plan of Correction:	This was corrected on 11/1/23. Participant declined to have photograph taken upon admission. Staff provided a written physical description of participant in lieu of photograph.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the center failed to post the findings of the most recent inspection of the facility. Evidence: During an inspection of the center on 11/1/23 with Staff# 2, the findings of the most recent inspection of the center were not observed to be posted.
Plan of Correction:	This was corrected on 11/1/23. Fire Inspection Report was posted while licensing was conducting inspection.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the center failed to ensure the sworn statement or affirmation be completed for all applicants for employment. Evidence: The record for Staff #2, date of hire 05/08/2023, contained documentation that Staff #2 did not complete a sworn disclosure until 11/3/2023.
Plan of Correction:	This was corrected on 11/3/23. Staff #2 completed and signed Sworn Disclosure and it was filed in the Staff's personnel record.