VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House on Laburnum Street
1453 Laburnum Street
Mc lean, VA 22101
(301) 656-8823

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Sept. 29, 2025

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

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: 09/29/2025, 1:40 P.M. to 2:40 P.M. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/13/2025, regarding allegations in the area(s) of: Administration and Administrative Services. 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: 1 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Activities and lunch Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-C
Description:	Based on facility incident report and staff interview, the facility failed to submit a written report of each incident specified in 22VAC40-73-70-A to the regional licensing office within seven days from the date of the incident and shall be signed and dated by the administrator and include a description of the incident, the circumstances under which it happened, and, when applicable, extent of injury or damage. Evidence: 1. Staff 1 submitted an incident report on 08/13/2025, stating that resident 1 was transported to the hospital for care. 2. On 09/29/2025, during an onsite inspection, the Licensing Inspector (LI) asked staff 1 about resident 1?s status. Staff 1 disclosed that resident 1 had died at the hospital on 08/18/2025. However, the LI only received the initial incident report dated 08/13/2025, with no follow-up report submitted within seven days to disclose the resident?s death. 3. Resident 1?s records confirm their death at the hospital on 08/18/2025.
Plan of Correction:	Administrator has been trained by the management team to send in follow-up reports for any incident report that would require that within seven days of the initial incident report being sent in.