VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cabrini Children's Center: Commonwealth Catholic Charities
2250 Pump Road
Richmond, VA 23233
(804) 362-0063

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: Sept. 12, 2022 , Sept. 13, 2022 and Sept. 14, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 INTRODUCTION 22VAC40-151 ADMINISTRATION 22VAC40-151 RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCY PLANNING

Comments:

Type of inspection: Monitoring. Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/12/2022 10:30 a.m. to 3:17 p.m. and 09/13/2022 2:00 p.m. to 3:30 p.m. Desk review of additional documentation was conducted on 09/14/2022. The Acknowledgement of Inspection forms were signed and left at the facility. Number of residents in care at the beginning of the inspection: No resident were in care. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. umber of resident?s records reviewed: 1 discharged resident?s record. Number of staff records reviewed: 5. Number of interviews conducted with residents :No residents were in care. Number of interviews conducted with staff: Two. 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 Connie McHale, Licensing Inspector at 804-662-7084 or email connie.mchale@dss.virginia.gov.

Violations:

Standard #:	22VAC40-151-190-B-1
Description:	Based on review of the personnel record for Staff S1,at the time of hire at the facility, the results of the TB (Tuberculosis) screening assessment documenting the absence of communicable TB was older than 30 days. Findings: 1. The TB screening assessment was dated 07/20/2022, which was older than 30 days. 2. Administrator A2 confirmed that the TB screening assessment was older than 30 days.
Plan of Correction:	The Program manager will work with Human Resources to develop a form to track new employee TB verification. This form will be required before placing an employee on work schedule at CRF.