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: April 15, 2025

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Technical Assistance:

290-A: Ensure lead staff person is designated on schedule. Medication Management Plan (Discussed previous changes requested) Allowable Variance Request

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/15/2025 08:30 AM to 1:05 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Meals, Activities, Medication Pass Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. 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. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-B
Description:	Based on facility document review and staff interview, the facility failed to ensure that the records of Private Duty Aides (PDA?s) included all required information. Evidence: 1. In an interview with the LI on 04/15/2025, staff 1 stated that there were two PDA?s providing companion services in the facility. 2. Staff 1 provided the Criminal Record Report (CHRR) for Collateral Contact 1 and Collateral Contact 2. Staff 1 stated there was no additional information available. Staff 1 confirmed the PDA files did not contain the required information.
Plan of Correction:	Facility will ensure all PDA files have all the required documentation.
Standard #:	22VAC40-73-290-B
Description:	Based on direct observation and staff interview, the facility failed to ensure the current on-site staff person in charge was posted. Evidence: 1. During a tour of the facility on 04/15/2025, the Licensing Inspector (LI) did not observe the current staff person on-site in charge posted. 2. In an interview with the LI on 04/15/2025, staff 4 confirmed they were the Designated Staff in Charge. 3. In an interview with the LI on 04/15/2025, Staff 1 confirmed the current staff in charge was posted.
Plan of Correction:	Facility will ensure that on-site staff person in charge is displayed for all who enter the community by adding language to the board that list what staff members are present for the day. A designation of ?Staff member in charge? will be added to the staff on duty board.
Standard #:	22VAC40-73-530-B
Description:	Based on direct observation and staff interview, the facility failed to ensure all doors to the outside remained unlocked. Evidence: 1. During a tour on 04/15/2025, the LI observed four doors to the outside locked. All four doors featured a deadbolt and handle lock. Two doors also featured a child safety lock over the doorknob. 2. In an interview with the LI on 04/15/2025, Staff 4 stated that doors stay locked all the time. Staff 4 attempted to show the LI how to open the side door to the patio with the child safety device; however, could not open the door with the lock installed. Staff 4 removed the child safety device to open the door. 3. In an interview with the LI on 04/15/2025, Staff 1 confirmed the doors were locked.
Plan of Correction:	Facility will change door hardware to be in compliance with regulation. Freedom of movement will be ensured by eliminating locks from the inside of doors leading to the exterior.
Standard #:	22VAC40-73-860-I
Description:	Based on direct observation and staff interview, the facility failed to ensure cleaning products were stored in a locked area. Evidence: 1. During a tour of the facility on 04/15/2025, the LI observed a container of ?CaviWipes? disinfecting towelettes in a metal wall bracket beside the front door. The bracket contained a label that stated, ?Not for Use on Skin.? The bottle was open with a wipe sticking out of the top. 2. In an interview with the LI on 04/15/2025, staff 1 and 2 confirmed they operate a mixed population facility. Staff 1 and 2 acknowledged the wipes were not stored in a locked area. 3. Photo Evidence Obtained.
Plan of Correction:	Facility will remove the CaviWipes located near the front door to the facility.