VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cobbdale Assisted Living 2
10617 Elmont Court
Fairfax, VA 22030
(571) 414-1850

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Nov. 18, 2021 and Nov. 22, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE.

Comments:

An unannounced mandated monitoring visit was conducted on 11/18/2021 and the exit interview was conducted on 11/22/2021. At the time of entrance seven residents were in care. The sample size consisted of four resident records, three staff records, and one individual interview. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 8/10/ 2021 were reviewed. Residents were observed eating breakfast and engaging in a physical exercise activity. Medication administration was observed. At the exit interview the violation notice was issued and risk ratings were reviewed. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via email at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-970-A
Description:	Based upon a review of records and interview, the facility failed to ensure that Fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: Administrator was unable to provide documentation of the most recent fire and emergency evacuation drills. The administrator admitted as of 11/18/2021, no fire and emergency evacuation drills had been completed.
Plan of Correction:	The facility will have monthly fire drills with staff and residents. This will be added to the monthly calendar to ensure it is carried out. The administrator will be directly responsible for implementing and maintaining this change.