VIRGINIA DEPARTMENT OF SOCIAL SERVICES

MADONNA HOME INC.
814 W. 37th Street
Norfolk, VA 23508
(757) 623-6662

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: June 10, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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: An unannounced renewal inspection took place on 06/10/2025 at 11:00 am until 12:00 pm. 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 4/30/2025 regarding allegations in the area(s) of: Resident Care And Related Services, Resident Accommodations And Related Provisions. Number of residents present at the facility at the beginning of the inspection: verify The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were: Resident Care And Related Services A violation notice was issued; any violation(s) not related to the complaint 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-550-B
Complaint related:	Yes
Description:	Based on the report received from the facility, the facility did not ensure that the resident has the right to voice or file grievances, or both, with the facility and to make recommendations for changes in the policies and services of the facility. The residents shall be protected by the licensee or administrator, or both, from any form of coercion, discrimination, threats, or reprisal for having voiced or filed such grievances. Evidence: 1. A complaint was received by the licensing inspector that the resident has expressed concerns about being afraid to voice concerns due to threats of being evicted. 2. During an interview with the resident, it was determined that the resident did not feel he could voice his concerns to the facility. 3. During an interview with Staff #1, it was determined that staff #1 did not address the residents concerns during the onsite visit on 6/10/2025.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Complaint related:	Yes
Description:	Based on the report received from the facility, the facility did not ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: 1. The record for Resident # 1, admission date of 3/20/24 contained a Resident?s Rights document dated 3/24/24 during the onsite visit on 6/10/2025. The Resident Rights were not reviewed annually with the Resident. 2. Staff #1 confirms the Resident Right form was dated 3/20/24 during the onsite visit on 6/10/2025.
Plan of Correction:	Not available online. Contact Inspector for more information.