VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Gates to Success ILA
1321 German School Road
Apt 103
Richmond, VA 23225
(804) 929-0712

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Nov. 13, 2024 and Nov. 15, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-131 Organization and Administration 22VAC40-131 Personnel 22VAC40-131 Additional Requirements for Specific Programs 22VAC40-191 Background Checks for Child Welfare Agencies

Comments:

Type of inspection: Renewal Dates of Inspection: The inspection was initiated on 11/13/2024 and concluded on 12/4/2024. An onsite office settings and conditions inspection was conducted on 11/13/2024 at 10am. A preliminary finding and exit meeting were conducted on 12/4/2024 @ 3p.m via teams meeting with Executive Director. Number of youths in care: 9 Number of youth records reviewed: 2 active records and 1 discharge record Number of staff records reviewed: 5 Number of interviews conducted with staff: 1 Additional Comments/Discussion: An entrance conference was conducted on 11/15/2024 at 1:33 pm with the Executive Director via phone. Personnel and youth records were requested and submitted by provider via email and reviewed on 11/21/2024. There were no changes to agency policies and procedures. The Executive Director was accessible via phone during the inspection. A preliminary finding and exit meeting were conducted on 12/4/24 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 can 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. 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: ww.dss.virginia.gov Should you have any questions, please contact Sherry Woodard, Licensing Inspector at (757) 987-0839 or by email at Sherry.Woodard@dss.Virginia.gov.

Violations:

Standard #:	22VAC40-131-290-C
Description:	Violation: Based on the review of the record for Foster Youth (FY1), and interview with agency representative (AR 1), the agency failed to address all required components of the licensing standards on the medical examination report. Findings: 1) Foster Youth (FY1) was admitted on 7/18/2024 and the medical examination report in record was signed and dated 7/5/2024. 2) The Licensing Inspector identified during the record review of (FY1) medical examination report that the section addressing communicable diseases, including tuberculosis was left blank. 3) Licensing inspector interviewed (AR 1) regarding the medical report for (FY1). a. During the exit meeting, inspection findings were reviewed with (AR1). Upon review of the youth medical examination document, the (AR1) acknowledged that the communicable disease section on the medical form was incomplete and left blank.
Plan of Correction:	Not available online. Contact Inspector for more information.