VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Culpepper Garden III INC
4439 N. Pershing Drive
Arlington, VA 22203
(703) 528-0162

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: Oct. 5, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE.

Comments:

A renewal inspection was initiated on 09/30/2021 and concluded on 10/5/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 71. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed four resident records, four staff records, menus, postings, activities calendar, staff schedules, and other documentation submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/05/2021. An exit interview was conducted with the Administrator on the date of inspection, 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. Exit interview with the Administrator. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-90-40-B
Description:	Based on record review the facility failed to ensure The criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. Evidence: Staff 4 was hired on 03/29/2021 and the criminal history record was dated 08/26.2021.
Plan of Correction:	During an internal audit it was identified that staff #4 was missing the background check documentation. The facility attempted to retrieve background check from VA state police but was unable to obtain due to it being past 90 days since background check was initially completed. The facility then re-ran the background check to ensure compliance. The status of the report received 8/26/2021 read NO IDENTIFIABLE RECORD(S) The business office manager shall complete another internal audit of all employees to ensure background checks are present in each employee file. If background check is not found during the audit, the facility shall re-run the background check to ensure compliance. The AL administrator will follow up to review team member files to ensure compliance upon hire.