VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living At Charlottesville
1550 Pantops Mountain Place
Charlottesville, VA 22911
(434) 977-4094

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: April 11, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 COMPLAINT INVESTIGATION

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: LI Poulter conducted an onsite inspection on October 11, 2023. LI Stevenson and LI Randolph conducted an onsite inspection on March 25, 2024. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on June 20, 2023, regarding allegations in the area of: Background checks for assisted living facilities. Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 Number of resident records reviewed: 0 Number of interviews conducted with residents: 0 Observations by licensing inspector: Additional Comments/Discussion: The designated manager on duty assisted LI Stevenson and LI Randolph during the onsite review conducted on 03/25/2024. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. 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. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov

Violations:

Standard #:	22VAC40-90-40-C
Complaint related:	Yes
Description:	Based on record review and interview, it was determined that the facility did not ensure that any person required by this chapter to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of a barrier crime. Evidence: 1) Employee #2?s date of hire was September 19, 2019. The criminal history report dated May 11, 2022, documented conviction of a barrier crime. Employee #2 continued to work at the facility until April 26, 2023. 2) Employee #1 confirmed that employee #2 remained employed by the provider until April 26, 2023.
Plan of Correction:	What Has Been Done to Correct? Employee #2 has been separated from the organization. How Will Recurrence Be Prevented? All associate hired by the Community would undergo a VA State criminal background check per the CSL company policy. In the event of a documented conviction of a barrier crime, such associate will not be employees to work for the community. Person Responsible: Executive Director and Business Office Manager