Facility Evaluation Report

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct the annual inspection. LPA met with Staff Nadia Falconer, designated representive in the absence of the administrator on the LIC 308 to explain the purpose of the visit to the administrator Iboni James via phone.

Physical inspection including but not limited to the common areas, resident bedrooms, resident bathrooms, exterior, kitchen and evacuation route gate. Facility is clean, the traffic areas are well lit and unobstructed. Only element of possible concern at this time was 2 exterior cameras(doorbell and exterior facing the backyard), LPA was provided information that they are not working, LPA gave guidance to add an admission agreement amendum explaining to potential residents the backyard and front door areas are under video but not audio surveillance. VMRC may have additional input about the use of exterior cameras.

LPA reviewed 3 staff files and 1 administrator file, one staff file did not provide evidence of annual continuing training since 2024, 1 administrator file did not provide evidence of hiv/bloodborne pathogen training since 2022. Staff files otherwise congruant with t22 requirements.

LPA reviewed 3 resident files, 1 resident file(r1) contains multiple(5+) significant incident reports for VMRC from the period 3/16/25 to 6/18/25, 5 of which contain alleged peer to peer physical assault or sexual assault allegations that occurred out in the community. Licensing side documentation of these incidents is absent or an unknown status except for 2. LPA was told by staff reporting requirement procedures were followed for the incidents, and at least 2 those reports were sent to community care licensing via email or fax. LPA is requesting supporting documentation (emails/fax reciepts to ccld) for all significant incident reports for the residents R1 and R2 from thier admission dates to today 6/2/26.