VIRGINIA DEPARTMENT OF SOCIAL SERVICES

First Choice West
826 Sturgeon Road
Lawrenceville, VA 23868
(804) 731-9662

Current Inspector: Belinda Dyson (804) 662-9780

Inspection Date: Dec. 13, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUNDS

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/13/2023 10:45 a.m.-1:10 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint/self-report was received by VDSS Division of Licensing on 11/28/2023 & 11/29/2023 regarding allegations in the area(s) of: Administration and Administrative Services, Building and Grounds, Resident Care & Related Services, Resident Care & Accommodations. Number of residents present at the facility at the beginning of the inspection: 2 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: NA Number of staff records reviewed: NA Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch meal Additional Comments/Discussion: Administrator was given the opportunity to ask questions An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s)/self-report); area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services A violation notice was issued; any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also be found on the violation notice. 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 Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	The facility did not report within 24 hours a major incident that could negatively affect the safety and health of the residents. Evidence:The facility failed to report the 3 residents were relocated briefly from 11/22/2023-11/24/2023 to the sister facility due to problems with the septic tank.
Plan of Correction:	If any incident happens at the facility, no matter how great or small or if anything out of the ordinary happens I will report to the Department of Social Services within 24 hours.