VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heavn On Earth Adult Day Center
3847 A South Crater Road
Petersburg, VA 23805
(804) 766-1110

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: April 16, 2024

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 63.2 GENERAL PROVISIONS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/16/2024 arrival time 1:10pm departure time 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 11 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with participants: Number of interviews conducted with staff: 2 Observations by licensing inspector: The participants were engaged in an activity upon arrival. Additional Comments/Discussion: 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. Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-260-B
Description:	Based on the review of participant records, the facility did not ensure that the required physical examination was on file at the center. Evidence: 1. Participants #1 and #2 did not have all of the required information in the physical on file at the center. 2. Participants #3 and #4 did not have physicals at all in the physical on file at the center.
Plan of Correction:	1. All required information on the physical for Participant #1 and #2 has been placed in the participant?s file at the center. Using DSS Model Form 22VAC40-61-260 2. Participant?s #3 and #4 physicals are onfile at the center. 3. Note: Physcials on Participant?s #2, #3, #4 over sight. They we?re on file at the time of visit.