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Inspection visit

Complaint

VILLAGE AT SYDNEY CREEK, THELicense 405800577
Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

On 12/22/20 at 11:53 am, LPA interviewed Staff #6 (S6), a management employee. S6 states that the administrator and wellness coordinate are not available on weekends. S6 says the LVN is the possible back-up on weekends; however, S6 believes “there is a lack of supervision.” S6 recalls a time when the Vice President of The Villages showed-up for a meeting with the administrator and waited 35-40 minutes for him to arrive. On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff. Staff #1 (S1) says that “Every other day he goes to Garden Creek or as needed when there’s a problem. He’s reachable. Even on weekends, he’ll answer maybe just a little later.” Staff #2 (S2) says “If his office is open, he is here.” S2 says they do not see the administrator in the afternoon. S2 voices “He needs to be here to know what’s going on, that we need more staff.” S2 further states that it would be better if he was here all the time, and not split between Sydney Creek and Garden Creek. Staff #3 (S3) states that they do not see the administrator very often because S3 works in the facility’s neighborhoods and don’t spend much time outside the neighborhoods. S3 says they “saw Kirk about one to two times per week. I knew he was the executive director, but didn’t know him and only spoke to him a couple of times.” Staff #4 (S4) says they don’t notice the hours the administrator is in the building. Staff #5 (S5) says “If he’s not here, he answers his phone, he calls or texts. The only time he’s not available is when he’s on vacation.” S5 explains that “The facility has a strong, capable management team who works really well together and would be strong regardless of whether Kirk was the Executive Director or not.” Based on the evidence obtained, the allegation ““Facility Administrator is not at the facility a sufficient number of hours, ” is deemed Unsubstantiated at this time . The administrator appears to be in the facility at minimum the required hours. However, based on staff comments, there is evidence to suggest the facility administrator should be in the building more hours to properly communicate with staff on the facility’s needs. Technical assistance is being given to educate on the requirement for administrator hours.

Citations

1 citation recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(a)(3)Type B

    87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (3) Fires or explosions which occur in or on the premises shall be reported immediately to the local fire authority; in areas not having organized fire services, within 24 hours to the State Fire Marshal; and no later than the next working day to the licensing agency. This is a potential safety hazard to residents in care. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not report a fire incident to CCL.

FAQ · About this visit

Common questions about this visit

What happened during the August 4, 2022 inspection of VILLAGE AT SYDNEY CREEK, THE?

This was a complaint inspection of VILLAGE AT SYDNEY CREEK, THE on August 4, 2022. The inspection found no deficiencies and no citations were issued.

Were any citations issued to VILLAGE AT SYDNEY CREEK, THE on August 4, 2022?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.