VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pauline's Pavilion, LLC
19312 White Oak Road
Sutherland, VA 23832
(804) 265-8708

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: July 2, 2019

Complaint Related: No

Areas Reviewed:

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

Technical Assistance:

As of 7/2/2019 The Licensing Inspector has not received the facility Renewal Application.

Comments:

A Representative with the Division of Licensing completed an unannounced, mandated, renewal inspection on 07/2/2019 from 4:15pm to approximately 6:25pm. At the point of entrance the facility had 15 residents in care. During the Licensing Inspection the Inspector reviewed 6 resident records and 3 staff records, observed the facility physical plant, observed the facility medication administration pass, first aid kit and observed residents during meal times. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact the facility Licensing inspector Kimberly Rodriguez at 804-662-9787 or by e-mail at kimberly.rodriguez@dss.virginia for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-210-A
Description:	Based on staff record review the facility failed to ensure a facility licensed for residential living care, all direct care staff attended at least 14 hours of training annually. Evidence: on 07/02/2019 with the facility Licensing Inspector and the facility Administrator, documentation showed that staff #1 did not have any hours of annual training completed.
Plan of Correction:	Not available online. Contact Inspector for more information.