Inspection · 2023-10-05
(804) 840-8260
Areas Reviewed
8VAC20-780 Administration.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies.
Inspector Notes
An unannounced inspection was conducted on 10/5/2023 in response to a complaint that was received by the licensing department on 10/3/2023 regarding allegations of noncompliance in the areas of record keeping and procedures for emergencies. The inspector was on site from approximately 9:05 am to 12:15 pm. Interviews with staff were completed, observations were made in the center, and documentation was reviewed.
The preponderance of the evidence gathered during the investigation supports part of the allegation; therefore, the complaint is determined to be valid. See the violation notice for more details.
Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.
Violations
1Based on a review of documentation and interview, the center did not ensure to maintain documentation of emergency evacuation drills that included the date and time of the drill as required.
Evidence:
1. A 2023 drill log was reviewed. Six of the nine monthly drill entries did not contain the time of the drill. The June evacuation drill contained a date error.
2. Administration stated that the drills were conducted but not logged promptly which resulted in errors in the required documentation.
signature the completion of every fire
and evacuation drill for the period of up
to 12 months.