VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Angel's Adult Daycare Center LLC
430 North Main Street
Suffolk, VA 23434
(757) 334-0474

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Oct. 13, 2021

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 GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS

Comments:

An initial inspection was initiated on 10-13-2021 and concluded on 10-14-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 0. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed the staff information sheet submitted by the center to ensure documentation was complete. One inspector and LA conducted the on-site portion of the inspection on 10-14-2021. An exit interview was conducted with the Administrator on 10-14-2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-61-50-B
Description:	Description: Based on observation and interview, the center failed to ensure the rights of participants are printed in at least 14-point type and posted conspicuously in a public place in the center. Evidence: 1. On 10-14-2021, during an inspection of the center with Staff #1 and Staff #2, the Licensing Inspectors did not see the rights of participants posted in the center. 2. During interview on 10-14-2021, Staff #1 and Staff #2 acknowledged the rights of participants were not posted in the center.
Plan of Correction:	1. The center's Director posted the rights of participants on the Angel's Adult Day Care Center LLC's bulletin board for the program participants to review.
Standard #:	22VAC40-61-50-D
Description:	Description: Based on observation and documentation, the center failed to ensure the posting of the name and telephone number of the appropriate regional licensing administrator of the department; the Adult Protective Services toll-free telephone number; the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any local ombudsman program servicing the area; and the toll-free telephone number of the disAbility Law Center of Virginia. Evidence: 1. On 10-14-2021, during an inspection of the center with Staff #2, there was not a posting in the center that included the name and telephone number of the appropriate regional licensing administrator of the department; the Adult Protective Services toll-free telephone number; the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any local ombudsman program servicing the area; and the toll-free telephone number of the disAbility Law Center of Virginia.
Plan of Correction:	1. The center's Director has posted on Angel's Adult Day Care LLC bulletin board the contact information for the regional licensing administrator of the department, the Adult Protective Service toll-free telephone number, the phone number for the Virginia Long-Term Care Ombudsman Program and the Disability Law Center of Virginia.
Standard #:	22VAC40-61-330-D
Description:	Description: Based on discussion, the center failed to have a designated staff person responsible for managing or coordinating the structured activities program that meets at least one of the qualifications as listed in the standard. Evidence: 1. During interview on 10-14-2021 with Staff #1, Staff #2, and Staff #3, the center does not have a staff person qualified to manage or coordinate the structured activities program.
Plan of Correction:	1. The center's Director has a delegated staff person responsible for managing and coordinating the structured activities program that meets one year full-time work experience within the last five years in an activities program in an adult care setting.
Standard #:	22VAC40-61-330-G-5
Description:	Description: Based on observation, the center failed to ensure the current month's schedule of activities is posted in a readily accessible location in the center. Evidence: 1. On 10-14-2021, during an inspection of the center with Staff #2, the September 2021 activity calendar was posted in the center. 2. During interview on 10-14-2021, Staff #2 acknowledged the current month?s schedule of activities was not posted in the center.
Plan of Correction:	1. The center's Director has updated and posted the current activities calendar (November) on Angel's Adult Day Care Center's bulletin board.
Standard #:	22VAC40-61-330-J
Description:	Description: Based on observation and discussion, the center failed to ensure adequate supplies and equipment appropriate for the program activities are available in the center. Evidence: 1. On 10-14-2021, during an inspection of the center with Staff #2, the center was unable to present adequate supplies and equipment appropriate for the program activities. 2. During interview on 10-14-2021, Staff #2 acknowledged adequate supplies and equipment were not currently available in the center to implement the program of activities.
Plan of Correction:	1. The center's Director has placed adequate supplies and equipment for the program activities (activity supplies/wheel chair/dividers).
Standard #:	22VAC40-61-360-B
Description:	Description: Based on observation and documentation, the center failed to ensure menus for meals and snacks for the current week are dated and posted in an area conspicuous to participants. Evidence: 1. On 10-14-2021, during an inspection of the facility with Staff #2, the Licensing Inspectors observed the menu for meals for the current week posted in the center. The posted menu was dated for September 2021. Additionally, there was not a menu for snacks for the current week posted in the center. 2. During interview on 10-14-2021, Staff #2 acknowledged the date on the posted menu for meals was not current.
Plan of Correction:	1. The center's Director has updated the menu for meals to reflect the current week/month and snack selection.
Standard #:	22VAC40-61-410-A
Description:	Description: Based on observation and interview, the center failed to ensure the interior and exterior of all buildings are maintained in good repair, kept clean and free of rubbish, and free from safety hazards. Evidence: 1. On 10-14-2021, prior to entering the center, there were several limbs and branches in the front of the center and front walkway as well as noted on the roof. The front walkway consisted of brick walkway which was unleveled and rising. 2. On 10-14-2021, during an inspection of the center with Staff #2, the railing in the back of the center was noted to have chips, dry rot, and exposed nails. 3. On 10-14-2021, upon entry from the back of the center with Staff #2, which Staff #2 states will be the area for participant discharge and pick-up, there was flooring missing with exposed plywood and frayed carpet. The room also had boxes stacked in the corner which could be a safety hazard. Additionally, there were two drawers stacked on top of each other that were not secured. 4. During discussion on 10-14-2021, Staff #2 acknowledged the safety hazards and repair opportunities identified by Licensing Inspectors during the on-site inspection.
Plan of Correction:	1. The center's Director has removed the limbs and branches that were present in front of the center, front walkway, and roof. Angel's Adult Day Care Center LLC participants have been instructed to enter from the rear of the facility where the ramp is present and the payment is level and safe. 2. The center's Director has repaired/painted the railing in the rear of the facility to remove the hazards. 3. The center's floor in the participant discharge and pickup area was repaired to remove the hazard.
Standard #:	22VAC40-61-440-B-3
Description:	Description: Based on observation and discussion, the center failed to ensure an area for supervised outdoor activities be equipped with appropriate seasonal outdoor furniture. Evidence: 1. On 10-14-2021, during an inspection of the center with Staff #2, the area available and accessible for supervised outdoor activities was shown without any appropriate seasonal outdoor furniture. 2. During interview on 10-14-2021, Staff #2 acknowledged that currently there is not any appropriate seasonal outdoor furniture for participants to utilize during supervised outdoor activities.
Plan of Correction:	1. The center's Director has purchased appropriate seasonal outdoor furniture for the supervised outdoors activities area.
Standard #:	22VAC40-61-480-C
Description:	Description: Based on observation and discussion, the center failed to have a minimum of (i) one pillow covered with a pillow case, (ii) two sheets, and (iii) one blanket, spread, or covering per bed or cot provided for the rest area. Evidence: 1. On 10-14-2021, during an inspection of the center with Staff #2, there was not a minimum of (i) one pillow covered with a pillow case, (ii) two sheets, and (iii) one blanket, spread, or covering per bed or cot present at the center for the rest area. 2. During interview on 10-14-2021, Staff #2 acknowledged these items were not currently present at the center, but stated they have been purchased.
Plan of Correction:	1.The center's Director has placed the pillow covered with a pillow case, two sheets, and one blanket in the facility in the rest area of the facility.
Standard #:	22VAC40-61-530-B
Description:	Description: Based on observation and discussion, the center failed to ensure a fire and emergency evacuation drawing showing primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers shall be posted in a conspicuous place. Evidence: 1. On 10-14-2021, during an inspection of the center with Staff #2, there was not a fire and emergency evacuation drawing posted in the center. 2. During interview on 10-14-2021, Staff #2 acknowledged there was not a fire and emergency evacuation drawing posted in the center.
Plan of Correction:	1. The center's Director has posted Angel' Adult Day Care LLC's fire and emergency evacuation drawing on the center's bulletin board.
Standard #:	22VAC40-61-550-A
Description:	Description: Based on observation and discussion, the center failed to ensure each building of the center and all vehicles being used to transport participants shall contain a first aid kit which shall include a list of items as identified in the standard. Evidence: 1. On 10-14-2021, during an inspection of the center with Staff #2, the first aid kit of the building and vehicle were reviewed. The building first aid kit did not include a small operable flashlight. The vehicle first aid kit did not include a first aid instructional manual. 2. During interview on 10-14-2021, Staff #2 acknowledged the two missing items from the building and vehicle first aid kits.
Plan of Correction:	1. The center's Director has placed a small operable flash light in the building and vehicle for Angel's Adult Day Care Center LLC. 2. The center's Director has placed a first aid instructional manual in the Angel's Adult Day Care Center LLC's first aid kit.