VIRGINIA DEPARTMENT OF SOCIAL SERVICES

South Richmond Adult Day Care Center
801 Prince Hall Drive
Richmond, VA 23224
(804) 310-4695

Current Inspector: Kimberly Davis (804) 356-3572

Inspection Date: May 16, 2025

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 22VAC40-80 THE LICENSING PROCESS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 CRIMINAL PROCEDURES 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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5-16-25 from 10:12 a.m.-12:30 p.m. 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: 22 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with participants: 2 Number of interviews conducted with staff: 1 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection- center documentation, center postings, first aid kit, lunch meal/menu, participant activities. An exit meeting was 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-340-B
Description:	Based on a review of facility documentation the facility failed to ensure that when any portion of an adult day center is subject to inspection by the Virginia Department of Health, the center shall be in compliance with those regulations, as evidenced by an initial and subsequent annual report from the Virginia Department of Health. The report shall be retained at the center for a period of at least two years. Evidence: The center failed to retain documentation of a current annual health inspection report as the report provided during the inspection was dated 1-31-24.
Plan of Correction:	To address this compliance issue, South Richmond Adult Day Care Center (SRADCC) will stay on schedule with the relevant Inspection Agency to ensure annual health inspection reports are provided promptly. Moving forward, the center?s leadership will take immediate action to ensure up-to-date documentation is maintained. 1. The center?s administration will follow up with health inspectors to confirm report availability immediately after inspections. 2. Upon receipt, the annual health inspection report will be promptly stored onsite in an accessible and clearly labeled compliance folder. Report obtained from the Health Inspection Agency and submitted to DSS for proof that the Inspection was conducted in 2025. Preventative Measures To prevent future violations, SRADCC will implement the following measures: 1. Designated Compliance Lead o A staff member will be assigned as the Compliance Lead, responsible for ensuring all inspection reports, including annual health reports, are requested, documented, and retained onsite. 2. Documentation and Recordkeeping o A documentation checklist will be established to track inspection timelines and ensure accountability for receiving reports. o All reports from any agency will be scanned and saved digitally in a secured compliance file and a hard copy will be filed in the onsite compliance folder. 3. Communication with Inspection Agencies o SRADCC will request immediate delivery of reports directly after each inspection. Communication between SRADCC and inspection agencies will be streamlined by establishing a standing follow-up protocol. 4. Internal Audits o Quarterly internal audits will be conducted to ensure all necessary documentation, including inspection reports, is properly retained and up to date.