VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Born to Care LLC
827 Big Bethel Road
Hampton, VA 23666
(757) 323-7272

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: June 18, 2025

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/18/2025 (arrival 10:04 a.m. / departure 12:05 p.m.). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Darunda Flint, Licensing Inspector at 757-807-9731 or by email at Darunda.a.flint@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-750-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure the resident bedrooms contain all required items. Evidence: 1. Resident rooms #1, #2, #3,and #4 did not contain at least one mirror. 2. Staff #1 and #2 acknowledged the aforementioned resident rooms did not contain at least one mirror.
Plan of Correction:	The facility staff purchased four 12 x 48 length mirrors and placed one in each room in a neutral location to be used by facility residents to allow them to view their appearance as needed. The facility?s Administrator, care staff or designee will monitor the mirrors daily to make sure they stay dust free and free from stains. They will also monitor for any cracks or chips in the glass to make sure they are always safe to be used by the facility residents. Any mirrors needing to be replaced will be replaced within 24-hours of any unusual findings.
Standard #:	22VAC40-73-960-B
Description:	Based on observation and staff interviewed, the facility failed to ensure there was a fire and emergency evacuation drawing posted in a conspicuous place on used by residents. The drawing shall show primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes and fire extinguishers, as appropriate. Evidence: 1. During a tour of the facility, the emergency exit plan posted did not include the assembly areas, areas of refuge, and telephones. 2. Staff #1 acknowledged the aforementioned were not included in the posted emergency exit plan.
Plan of Correction:	The Facility Administrator updated and corrected the drawing of the emergency exit plan to include assembly areas, areas of refuge, and telephones. The new drawing indicates these areas and items by using a color coded map key to make it easier to understand. The emergency exit drawing will be posted on the wall next to the front entrance. Administrator or designee will monitor the emergency exit drawing quarterly and update it with any needed changes within 24-hours to make sure the plan stays in compliance with Virginia DSS licensing standards.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all required items. Evidence: 1. On 06/18/2025, the first aid kit did not include a disposable single-use breathing barrier or shields for use with rescue breathing or CPR, and triangular bandages. 2. Staff #2 acknowledged the first aid kit did not include all required items.
Plan of Correction:	The Facility?s Health Care Manager ordered and replaced the missing items from the first aid kit the same day of the monitoring inspection. The Health Care Manager of designee will monitor the first aid kit on the first Monday of every month to make sure it is not missing any items and that the first aid kit stays in compliance with Virginia DSS licensing standards. Any missing items will be ordered and replaced within 24-hours. A check-off sheet with a list of requested items will be used to assist the facility with its on-going monitoring process.