Current Inspector:
Margaret T Pittman
(757) 641-0984
Inspection Date:
Sept. 8, 2022
Complaint Related:
No
Areas Reviewed:
22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 SUPERVISION 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS
Comments:
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/08/2022 from 11:54 am to 1:10 pm. 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: 0 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Additional Comments/Discussion: LI and LA conducted initial inspection of the center.
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law.
If the applicant 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 should the facility be issued a license to operate.
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 a licensed facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on observation, 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. During an inspection of the center with Staff #1 and Staff #2, the rights of participants were not posted in the center.
Plan of Correction:
Poster size (36x48) signage of Rights of Participants has been posted in minimum 16 point font posted conspicuously in center of main activity area.
Standard #:
22VAC40-61-50-D
Description:
Based on observation, 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. During an inspection of the center with Staff #1 and 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:
Signage of Emergency contacts, Interim Regional Licensing Administrator, Adult Protective Services, VA Long- Care Ombudsman Program and Bay Aging as well as disAbility Law Center of Virginia phone numbers, emails, and websites provided. Signage posted next to Rights of Participation in a conspicuous space in the center of the main activity area.
Standard #:
22VAC40-61-330-G-5
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. During an inspection of the center with Staff #1 and Staff #2, the activity calendar was not posted in the center.
Plan of Correction:
Monthly Activities and Daily Schedules are posted conspicuously in a readily accessible location in the main activity area.
Standard #:
22VAC40-61-360-B
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. During an inspection of the facility with Staff #1 and Staff #2, the menu for meals for the current week was not posted in the center.
Plan of Correction:
Menus for meals and snacks for current and next week are dated and posted in an area conspicuous to participants.
Standard #:
22VAC40-61-440-B-3
Description:
Based on observation, the center failed to ensure an area for supervised outdoor activities be equipped with appropriate seasonal outdoor furniture.
Evidence:
1. During an inspection of the center with Staff #1 and Staff #2, the area available and accessible for supervised outdoor activities was shown without any appropriate seasonal outdoor furniture.
Plan of Correction:
All outdoor furniture was purchased after confirmation of inspection. All outdoor furniture is weatherproof appropriate for activities.
Standard #:
22VAC40-61-460-H
Description:
Based on observation, the center failed to ensure hot water at taps available to participants are maintained within a temperature range of 105?F to 120?F.
Evidence:
1. During an inspection of the center with Staff #1, the hot water temperature in one of the two bathrooms to be utilized by participants read 133?F.
Plan of Correction:
Temperature was adjusted to 115 degrees Fahrenheit.
Standard #:
22VAC40-61-530-B
Description:
Based on observation, 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. During an inspection of the center with Staff #1 and Staff #2, the fire and emergency evacuation drawings were not posted in the center.
2. Upon review of the available drawings with Staff #1, they did not include areas of refuge, assembly areas or telephones.
Plan of Correction:
Existing onsite drawings were updated to include the missing component of location of accessible phone, area of refuge, and assembly area. All other details were preexisting on drawings. Updated drawings were posted in accordance with location of each drawing. Facility is only licensed for one area currently as update of Occupancy is being reviewed. It was assumed the area mandated for 2 hour fire proofing and only area allowed for service was Assembly area. All details were updated to reflect code.
Standard #:
22VAC40-61-550-A
Description:
Based on observation, the center failed to ensure each building of the center contain a first aid kit which shall include a list of items as identified in the standard.
Evidence:
1. During an inspection of the center with Staff #1 and Staff #2, the first aid kit of the building did not include scissors or tweezers.
Plan of Correction:
Medical Scissors and Tweezers were added to First Aid Kit within service location.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
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http://www.dss.virginia.gov/facility/search/adc.cgi