VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cobbdale Assisted Living (Fairfax Co)
3503 Burrows Avenue
Fairfax, VA 22030
(571) 414-1850

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Jan. 26, 2024

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 22VAC40-80 THE LICENSING PROCESS

Technical Assistance:

Documentation was discussed with the provider.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/26/24 (8:20 AM - 1:00 PM). Number of residents present at the facility at the beginning of the inspection: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, medication administration, activity 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-200-C
Description:	Based on record review, the facility failed to ensure that each direct care staff member meets one of the required qualifications. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment. Evidence: One out of three staff records (Staff #2) did not contain one of the required direct care staff qualifications. Staff #2 has a hire date of 8/25/23, but her record did not contain documentation that she met one of the direct care staff qualifications listed in 22VAC40-73- 200-C.
Plan of Correction:	Staff member (Staff #2) will have all of her direct care staff qualifications. Cobbdale has reached out to a certified direct care staff trainer to perform the direct care staff training.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Evidence: One out of three staff records (Staff #3) did not contain current certification in first aid. The record for Staff #3, hired 6/13/23 as a CNA, contained documentation of current CPR/AED certification. Staff #3's record did not documentation of current first aid certification. Facility staff confirmed that Staff #3's record did not contain documentation of current first aid certification.
Plan of Correction:	Direct Care staff member #3 will complete their first aid training, and present their new first aid card to Cobbdale.