Golden Years and More — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Golden Years and More was inspected 6 times between May 14, 2021 and October 8, 2025 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 30 violations under 24 distinct standards.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 5 of these 6 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

Two Year

License expires

11/26/2027

Administrator

Philip Calubaquib

Licensing inspector

Patricia Koval

Inspector phone

(804) 621-6046

Approved for

Assisted Living · Non-Ambulatory

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

October 8, 2025Inspection6 violations

Inspection dates

10/08/2025

Areas reviewed

Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessBackground Checks for Assisted Living FacilitiesSworn Statement

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/8/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 3 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed residents participating in activity programs and eating breakfast. Additional Comments/Discussion: 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations

22VAC40-73-120-A

Based on staff record review, the facility failed to document required orientation and initial training.

Evidence

The staff file for staff 1 hired 5/19/2025 did not include all required orientation and initial training.

Plan of correction

Not published by VDSS.

22VAC40-73-325-B

Based on resident record review and staff interview, the facility failed to complete a fall risk rating by the time comprehensive ISP is completed and at least annually.

Evidence

Resident 1 admitted on 2/7/2025 did not have a fall risk rating on file.
Staff 2 stated she did not see a fall risk rating for resident 1.
Resident 2 admitted in February 2020 did not have a fall risk rating on file.

Plan of correction

Not published by VDSS.

22VAC40-73-450-A

Based on resident record review, the facility failed to, on or within seven days prior to the day of admission, develop a preliminary plan of care.

Evidence

Resident 1 admitted on 2/7/2025 had an Individualized Service Plan on file dated 2/20/2025.

Plan of correction

Not published by VDSS.

22VAC40-90-40-B

Based on staff record review, the facility failed to obtain within 30 days of employment a criminal history record report.

Evidence

Staff 1 hired 5/19/2025 had a criminal history record report on file dated 7/7/2025.

Plan of correction

Not published by VDSS.

22VAC40-73-440-A

Based on resident record review, the facility failed to assess all residents using the uniform assessment instrument (UAI) prior to admission.

Evidence

Resident 1 admitted on 2/7/2025 had a UAI on file dated 2/20/2025.

Plan of correction

Not published by VDSS.

22VAC40-73-260-A

Based on staff record review and staff interview, the facility failed to ensure each staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.

Evidence

Staff 1 hired on 5/19/2025 did not have a current first aid certificate in the staff file on the date of inspection on 10/8/2025.
Staff 2 stated staff 1 was scheduled to attend first aid training.

Plan of correction

Not published by VDSS.

November 7, 2024Inspection11 violations

Inspection dates

11/07/2024

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/7/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 3 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed residents eating meals and participating in activity programs. Additional Comments/Discussion: 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations

22VAC40-73-710-D

Based on observation and staff interview, the facility failed to keep a record of restraint usage, outcomes, checks, and any assistance required in subdivision 4 of this subsection and shall note any unusual occurrences or problems.

Evidence

Licensing inspector observed Resident 1 in bed with bedrails in the up position.
Staff 1 stated the staff check on Resident 1 every 30 minutes but did not know they were to documents these checks.

Plan of correction

The facility staff check residents using restraints every 30 minutes, but failed to document checks. The staff will now document any unusual occurrences/problems. Resident I’s full bed rail will be reduced to a half bed rail or partial bed rail that will not restrict resident’s freedom of movement

22VAC40-73-550-G

Based on resident record review and staff interview, the facility failed to review the rights and responsibilities of residents with the resident or legal representative annually.

Evidence

Resident 1 had a review of residents right on file dated 5/30/2023 and Resident 2 did not have an annual resident right review on file within the last year.

Plan of correction

The facility will review the rights and responsibilities of residents with the resident or legal representative annually.

22VAC40-73-950-E

Based on facility records review, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents and volunteers.

Evidence

The last two reviews by staff of emergency preparedness and response plan was conducted on 8/12/2023 and 2/14/2024.

Plan of correction

The semi-annual Emergency Preparedness and Response Plan Orientation and Review will be developed and implemented twice a year. 8/14/2024 and 2/14/2025

22VAC40-73-490-A

Based on facility record review, the facility failed to have a licensed health care professional, practicing within the scope of his professional shall provide healthcare oversight at least every six months.

Evidence

The last Health Care Oversight on file was conducted on 2/18/2024.
Staff 1 stated the facility employs a part-time nurse.

Plan of correction

Health Care oversight will be done quarterly by an LPN who works at the facility part time. Last HCO: 2/18/2024

22VAC40-73-150-B-1

Based on staff interview, the facility failed to notify the department’s regional licensing office in writing within 14 days of a change in a facility’s administrator, including resignation of an administrator, appointment of an acting administrator, including, and appointment of a new administrator, except that the time period for notification may differ as specified in subdivision 2 of this subsection.

Evidence

Staff 1 informed me that the administrator on file’s Assisted Living Facility Administrator (ALFA) license expired on 3/31/2022 and she was not aware until recently.
Licensing inspector confirmed by license lookup on Department of Health Profession website that Staff 3’s ALF license expired on 3/31/2022

Plan of correction

Both ALFA’s licenses expired on 3/31/22. However, DHP.Virginia.gov renewal link was active until November 2024. We were able to renew and pay every year until November 2024 and was just now informed that our licenses were already expired. Reinstatement is in process for Philip Calubaquib. Melissa Weatherholtz license is already reinstated and renewed

22VAC40-73-140-E

Based on staff record review and staff interview, the facility failed to have an administrator licensed as an assisted living facility administrator on record.

Evidence

Staff 1 stated Staff 3’s ALFA license expired on 3/31/2022.
The department’s regional licensing office was not informed of the appointment of an acting administrator.

Plan of correction

Reinstatement and Renewal Requirements were completed and submitted to DHP VA. Philip Calubaquib’s reinstatement is “pending”. Melissa Weatherholtz license is now reinstated, renewed and active.

22VAC40-73-990-B

Based on facility records review, the facility failed to review the procedures and the plan for resident emergencies with staff every six months and document the review with each staff member.

Evidence

The last review by staff on file was conducted on 2/14/2024.

Plan of correction

Resident Emergencies & Procedures and Plan will be reviewed with every staff every six months and will be documented. 2/14/2024, 8/14/2024 & 2/14/2025

22VAC40-73-350-B

Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.

Evidence

Staff 1 stated ‘I don’t think I have it’ and was never supplied to the licensing inspector during the time of inspection.

Plan of correction

The facility will check with the Registry of Sex Offenders on the State Police Website before admitting a new resident if potential resident is a registered sex offender.

22VAC40-73-450-C

Based on resident record review, the facility failed develop an Individualized Service Plan (ISP) that identified the needs and dates identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning if appropriate; and (vi) other sources.

Evidence

Resident 1 had a Fall Risk Assessment Tool completed on 12/14/2023 that assessed the resident as ‘High Fall Risk’.
The ISP developed on 8/25/2024 did not list interventions to prevent or reduce falls.

Plan of correction

Staff I will develop an ISP that will identify the needs and dates identified on the UAI. Resident I had a High Risk Fall Assessment Tool on 12/14/23. The ISP that was done on 8/25/24 should have had this information. Any resident assessed with HFR based on the UAI will have the list of interventions to prevent or reduce falls on the ISP.

22VAC40-73-680-I

Based on resident record review, the facility failed to, at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medication administered to residents, including over-the-counter medications and dietary supplements including the date and time given and initials of direct care staff administering the medication.

Evidence

Resident 1’s MAR for November 1-6, 2024 did not include dates and time given or the initials of the direct care staff administering the medication for the following medications: Donepezil HCL 5 mg tablet(prescribed 9/19/2018), Vitron-C Tablet (prescribed 5/26/2020), Vitamin B-12 1000 mcg tablet (prescribed 6/3/2021), Vitamin D 2000 unit tablet (prescribed 6/3/2021), and Loratadine 10 g tablet (prescribed 6/3/2021).
Resident 2’s MAR for November 1-6, 2024 did not include dates and time given or the initials of the direct care staff administering the medication for the following medications: Tramadol HCL 50 mg tablet (prescribed 10/28/2024, Methenamine HIP 1 gm (prescribed 10/1/2024), Ferrous Sulfate 325 mg tab (prescribed 10/28/2024), Quietiapine FUM 50 mg Tab (prescribed 10/1/2024), Donepezil HCL 10 mg tab (prescribed 10/1/2024), Mirtazapine 15 mg tab (prescribed 9/1/2024).

Plan of correction

The MAR used in the facility will be changed. Each medicine will have its own MAR, initial of the Med-aide, dosages, and its indication/diagnosis for each resident.

22VAC40-73-690-B

Based on resident record review, the facility failed to, for each resident assessed for assisted living care, except for those who self-administer all of their medications, a licensed health care professional, practicing within the scope of his profession, shall perform a review every six month of all the medications of the resident.

Evidence

The Bi-yearly Review of Resident Medications on file for Resident 1 was not dated.
The Bi-yearly Review of Resident Medications on file for Resident 2 was dated 11/3/2022.

Plan of correction

The facility will have their LPN perform a review of all medications given to the residents. This will done every 6 months.

December 7, 2023Inspection3 violations

Inspection dates

12/07/2023

Areas reviewed

Comments

Date of Inspection: December 7, 2023 Type of Inspection: Monitoring inspection Census: 5 Number of records reviewed and interviews conducted- 6 records, 3 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The LI observed residents participating in independent activity programs and eating lunch. Licensing Inspector compared physician orders for medications to the medications available to be administered to the residents. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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 preventive measure(s).

Violations

22VAC40-73-320-A

Based on resident records review and staff interview, it was determined that the facility failed to, within 30 days preceding admission, have a physical examination by an independent physician.

Evidence

Resident A did not have a physical examination on file. Resident A was admitted on 11/29/2023.

Plan of correction

Not published by VDSS.

22VAC40-73-710-B

Based on direct observation, resident records review and staff interview, it was determined that the facility failed to have a physician’s written order or written consent from the resident’s legal representative prior to using a physical restraint (bedrail).

Evidence

Resident B was in bed with a bedrail in the up position while resident was in bed. Resident B did not have a written order for the physical restraint, nor was there written consent from the resident’s legal representative to use the physical restraint.

Plan of correction

Not published by VDSS.

22VAC40-73-660-A

Based on direct observation and staff interview, it was determined that the facility failed to lock a Schedule II drug under a separate locked storage compartment.

Evidence

Resident B’s prescribed Schedule II drug was inside an unlocked refrigerator in the kitchen.

Plan of correction

Not published by VDSS.

October 26, 2022Inspection7 violations

Inspection dates

10/26/2022

Areas reviewed

Comments

Date of Inspection: October 26m 2022 and November 3, 2022 Type of Inspection: Renewal inspection If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 5 Number of records reviewed and interviews conducted- 7 records, 2 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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 preventive measure(s). The completed corrective action needs to be in the licensing office by November 17, 2022

Violations

22VAC40-73-690-B

Based on record review and staff interview, it was determined that the facility failed to complete a Medication Review every six months.

Evidence

No Medication Review was documented within the last six months.

Plan of correction

A medication review will be conducted by a licensed pharmacist from Manassas Pharmacy every six months.

22VAC40-73-950-E

Based on record review and staff interview, it was determined that the facility failed to conduct a semi-annual review with staff.

Evidence

The last Emergency Preparedness review on file for staff was 2/14/22.

Plan of correction

Semi-review will be conducted with staff.

22VAC40-73-320-A

Based on resident record review and staff interview, it was determined that the facility failed to obtain admitting documentation as required.

Evidence

Res C had no initial tuberculosis risk assessment completed as required.

Plan of correction

Golden Years and More, ALF has all the admitting documentation as required prior to admission.

22VAC40-73-620-A

Based on record review and staff interview, it was determined that the facility failed to complete a dietary review of special diets every six months.

Evidence

The last dietary review on file was conducted on 11/15/21.

Plan of correction

The dietician reviewed and ultimately submitted the semi-annual review for November 2022 with her Dietetic Registration.

22VAC40-73-990-B

Based on record review and staff interview, it was determined that the facility failed to conduct resident emergencies review/drills with staff every six months.

Evidence

The last documented review of resident emergencies with staff was held on 11/7/2021.

Plan of correction

Semi-annual review will be held with staff.

22VAC40-73-450-A

Based on resident record review and staff interview, it was determined that the facility failed to develop a preliminary plan of care when the resident was admitted to facility.

Evidence

Res C was admitted on 10/21/2022 and had no documented preliminary plan of care on file at time of inspection on 10/26/2022.

Plan of correction

A preliminary plan of care will be developed prior to admission to Golden Years and More.

22VAC40-73-450-F

Based on resident record review and staff interview, it was determined that the facility failed to update the Individualized Service Plan to indicate a change in condition as required.

Evidence

Res B's Individualized Service Plan did not include Home Health Physical Therapy services.

Plan of correction

The Individualized Service Plan has been updated. Changes in the condition of the resident have been addressed to the Individualized Service Plan.

March 11, 2022Inspection3 violations

Inspection dates

03/11/2022

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS

Comments

Date of Inspection: March 11, 2022 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 4 Number of records reviewed and interviews conducted- 2 resident records and 2 staff records, 4 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The healthcare over sight report, dietician report, fire drill, activity schedule and menus were reviewed at the time of inspection. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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 preventive measure(s).

Violations

22VAC40-73-320-B

Based on resident record review and staff interview, it was determined that the facility failed to have documentation of a subsequent tuberculosis evaluation as required.

Evidence

Resident B had no socumentation of an annual risk assessment for tuberculosis as required.

Plan of correction

All residents in care will have annual tuberculosis risk assessments as required. Facility nursing staff will audit the records and ensure compliance.

22VAC40-73-940-A

Based on facility document review and staff interview. it was determined that the facility failed to have a current fire inspection as required.

Evidence

The last fire inspection documentation was 2019. There was no current fire inspection documentation.

Plan of correction

The fire marshal will be contacted to schedule an inspection to ensure complaince.

22VAC40-73-320-A

Based on resident record review and staff interview, it was determined that the facility failed to have admitting documentation as required.

Evidence

Resident A had no documentation of a physical prior to admission as well as no initial tuberculosis risk assessment as required.

Plan of correction

All new admissions will have the paperwork filled out as required. All admitting paperwork will be timely and will be reviewed by the facility nursing staff prior to admission.

May 14, 2021Inspection0 violations

Inspection dates

May 14, 2021 and May 25, 2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on May 14, 2021 and concluded on May 25, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 5. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed *2 resident records, and 2 staff records submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.