VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Candle Light Senior Manor
912 Maple Grove Drive
Richmond, VA 23223
(804) 716-3114

Current Inspector: Belinda Dyson (804) 662-9780

Inspection Date: Dec. 20, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUNDS 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/20/2023 from 10:15 a.m.-1:00 p.m. and on 1/4/2023 4:30 p.m.-5:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint was received by VDSS Division of Licensing on 12/19/2023 regarding allegations in the area(s) of: medication administration, the terms of the license and building and grounds Number of residents present at the facility at the beginning of the inspection: 10 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: physical plant, physician?s orders, medications, medication administration records, first aid kit supplies Additional Comments/Discussion: Administrator and staff were given the opportunity to ask questions. An exit meeting will be conducted to review the inspection findings. The department's inspection findings are subject to public disclosure. The evidence gathered during the investigation supported some, but not all of the allegations areas of non-compliance with standard(s) or law were: General Procedures 120 A.4 and Building and Grounds 900 5.a at this time. A violation notice was issued; any violation(s) not related to the complaint(s)but identified during the course of the investigation can also be found on the violation notice. 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. 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 Belinda Dyson, Licensing Inspector at 804 662-9780 or by email at Belinda.Dyson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-900
Complaint related:	Yes
Description:	Facility was found not to be in compliance with resident's sleeping quarters. Evidence: During a tour of the physical plant there were 3 resident?s beds in bedroom #2.
Plan of Correction:	Administrator will have the bed removed once the resident is placed with family or another facility on January 15, 2024. Administrator will comply with only 2 beds in a bedroom.
Standard #:	22VAC40-80-120-A-4
Complaint related:	Yes
Description:	The facility was found not to be within the Terns of the License issued by the Department of Social Services. Evidence: During a tour of the physical plant and interviews with staff, the facility has 10 residents in care. The license issued is for 8 residents only.
Plan of Correction:	Administrator will reduce to 8 residents as the license states. 2 residents will be placed with family or other facility in order to come into compliance with the license and regulations.