The most serious findings in the state inspection reports we hold: deaths, sexual and physical abuse, restraints that injured a child, suicide attempts, medical neglect and hospitalisations. Every quote below is the licensing agency's own wording, and each one was read against its report by a person before it was listed here.
Upon review of CHRIS entry A-20250006: Entity # 1's disposition received revealed the following: Individual #1's account of the incident was consistent regarding the inappropriate restraint which resulted in injury to Individual #1.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..
• Individual 1 reported to staff allegations of physical aggression by a peer to include sexual harassment and threats to harm.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-260. B. (2d) - Providers shall require their employees to: 2. Protect individuals from any form of abuse, neglect, or exploitation by: 2d. ....
Provider substantiated for sexual abuse based on the following: Review of camera footage revealed the following: On May 3, 2025, at approximately 9:36am, Individual #1 and Employee #1 entered the cool down/sensory room. Employee #1 and Individual #1 engaged in inappropriate touching, to include Individual grabbing Employee #1's waist band, slapping/smacking Employee #1 on the bottom several times, and Employee #1 grabbing/caressing Individual #1's face. [...] Employee #1 then performed oral sex on Individual #1 three times.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.. "[...]" marks text left out between sentences.
Upon review of CHRIS entry, A-20250021, the provider's investigation included the review of the provider's policy which revealed: · Employees #1, #2, and #3 did not adhere to the provider's protocol for active supervision, resulting in peer-to-peer aggression involving Individual #1 being sexually assaulted by another individual.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..
At the time of the inspection, there was visual evidence of an abusive action, specifically Staff #1 pushing/shoving Resident #1.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-920. (5) The following actions are prohibited: 5. Any action that is humiliating, degrading, or abusive;.
On December 29, 2024, Individual 1 reported to staff that a peer had touched Individual 1 with an unwanted sexual touch under a blanket on December 24, 2024. [...] Individual 1 and peer were separated following a utilization review committee meeting on January 7, 2025, nine days after Individual 1's initial allegation of unwanted sexual touching. The provider failed to take immediate steps to protect Individual 1 following an allegation of peer- on-peer unwanted sexual touching.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. D. (3b) (1) - The provider's duties: 3. Providers shall assure the following relative to abuse, neglect, and exploitation: 3b. The director .... "[...]" marks text left out between sentences.
Employee #5 pushed Individual #1 while trying to get the clipboard back. [...] Employee #9 was seen pushing Individual #1 to keep Individual #1 from hitting/kicking them.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-310. B. (3) Required annual retraining: 3. All child care staff shall receive annual retraining on the provider's behavior supports and timeout .... "[...]" marks text left out between sentences.
After reporting that another peer engaged in non- consensual sexual relations with them, Individual #1's mother reported that internal bruising was found during a medical exam.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..
Entity #2 informed Human Rights Advocate via letter dated October 31, 2024, that it was determined the disposition was Founded, Level One, for Sexual Abuse. Entity #2 reported to Human Rights Advocate that Employee #1 was charged with 7 felony counts of VA Code 18.2-370.1, Taking Indecent Liberties with Child by Person in Custodial or Supervisory Relationships.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..
In plain words: A staff member sexually abused a child in the program, sending graphic TikTok messages and arranging meetings in the group home bathroom, and also left other children unattended during the abuse, sometimes in the same bedroom while they slept. The state determined the abuse was substantiated. Our summary of the state's report. The state's own wording follows.
Provider substantiated for sexual abuse and psychological abuse based on the following: Provider found inappropriate TikTok messages between Employee #1 and Individual #1 on Individual #1's phone that were sexually graphic in nature and which discussed meeting up in the group home bathroom on more than one occasion, along with references to sexual interactions which included oral sex and sexual intercourse. [...] While Employee #1 engaged in sexually abusing Individual #1, Employee #1 failed to provide services necessary to the health, safety, and welfare of other minor individuals residing in the group home, leaving those individuals unattended during the sexual encounters with Individual #1, and, at times, engaging in the abuse in the same bedroom with other individuals while they were sleeping. ?
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.. "[...]" marks text left out between sentences.
Individual #1 reported a sexual assault to Employee #1 involving Individual #2.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..
Individual #1 was placed in a prone restraint that caused bruising and a bloody nose to Individual #1. [...] Based on the provider's investigative finding, there is a preponderance of evidence to support a substantiated finding of physical abuse.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.. "[...]" marks text left out between sentences.
Employee #1 used unauthorized physical restraint while de-escalating self-harm on Individual #1.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-110. A. Each individual is entitled to be completely free from any unnecessary use of seclusion, restraint, or time out..
Upon review CHRIS entry A- 20230020; the provider's investigation includes review of cameras and eyewitness statements which revealed that Employee # 1 had inappropriate sexual conversations and exchange letters with sexual content with Individual #1.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..
Based on these interviews, information reported was consistent in reports of both consensual and non-consensual sexual acts committed by Individual #1, Individual #6, and Individual #7.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-800. A. (1) There shall be evidence of a structured program of care designed to: 1. Meet the residents' physical and emotional needs;; 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;.
Three staff pushed Individual #1 into the seclusion room, stayed at the door for two minutes, then all three staff walked away.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-960. I. All space in the seclusion room shall be visible through the locked door, either directly or by mirrors.
Based on review of the internal incident report, the provider failed to implement prompt emergency care to Resident #1 after Resident #1 experienced a suicide attempt. There was a 9-minute period between the time Resident #1 was found after the suicide attempt and the provider decision to call EMS. Per video review of the incident, Resident #1 was discovered by Staff #1 and #2 at 5:01pm after the suicide attempt. Per the incident report, after a few minutes of asking Resident #1 questions, Staff #2 and Staff #6 made the determination that EMS personnel were needed and made a 911 telephone call. The incident report explained the call to EMS was not made until, "about 5:10pm," which was after the internal nursing staff was contacted.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-810. A. (3) The provider shall have and implement written procedures for promptly: 3. Providing emergency services for each resident;; 12VAC35-46-810. A. (4) The provider shall have and implement written procedures for promptly: 4. Providing emergency services for any resident experiencing or ....
Per provider's CHRIS report #A20230324, by a preponderance of the evidence which included eyewitness statements, failure to follow policy and witness credibility, the provider substantiated the allegation of neglect when Employee #1 used an improper restraint with Individual #1 which caused Individual #1 to sustain an injury to their arm.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..
Individual #1 was able to obtain large quantities of each medication from Employee #1’s personal belongings, and later ingest these medications while on the unit, which resulted in the individual being hospitalized and whom later died.
Therefore, Individual #1 had an opportunity to ingest Employee #1’s medications, which resulted in the individual being hospitalized, and whom later died.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-60. K. Providers shall not engage in willful action or gross negligence that jeopardizes the care or protection of residents.; 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;.
Individual #1 was physically assaulted a second time on 9/22/19 and during that assault there was again only one staff member present with the group of individuals.
The provider failed to report a Level II serious incident involving individual #1 which occurred 9/22/19 in which the individual was physically assaulted. [...] After Individual #1 is physically assaulted, the provider suggests, and offers to put into place, a corrective safety protocol. [...] Another Level II serious incident occurred on 9/22/19 in which Individual #1 was physically assaulted a second time and during that assault there was again only one staff member present with the group patients.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-105-150. (5) The provider including its employees, contractors, students, and volunteers shall comply with: 5. The provider's own policies. All ...; 12VAC35-105-160. D. (2) The provider shall collect, maintain, and report or make available to the department the following information: 2. Level II and Level .... "[...]" marks text left out between sentences.
Employee #1 continued to utilize excessive force, causing injury to Resident #1 before a three-person proper restraint was implemented.
Resident #1 was improperly restrained and remained in the care of Employee #1 in lieu of following their plan examples of "What helps me calm down or stay calm" and "What can staff do to help me" as outlined in their behavior support plan.
Employee #2 and Employee #3 arrived in the common area and witnessed Resident #1 being held down in an unapproved restraint.
Employee #1 was seen through video camera footage delivering several excessive and improper restraints towards Individual #1. Employee #1 is seen at one time pushing Individual #1's head into the door during a hold. [...] Use of excessive force when placing a person in physical or mechanical restraint; This regulation was NOT MET as evidenced by: Per the review of video camera footage by the Office of Human Rights Advocate and Office of Licensing Specialist #2 and Employee #3 watched Employee #1 place Individual #1 in an incorrect restraint without intervening.
A review of video footage on 7-25-22 for an incident occurring on 7-21-22 showed that Employee #1 used excessive force during an inappropriate physical altercation with Resident #1. Video footage reviewed on 7-25-22 confirmed that Employee #1 physically assaulted Resident #1 on 7-21-22. Video footage showed that Employee #2 and Employee #3 did not intervene appropriately when they witnessed Employee #1 holding Resident #1 in an inappropriate restraint. Employee #2 and Employee #3 walked around Employee #1 holding Resident #1 in an inappropriate restraint.
From the state's report. Non-compliance, DBHDS investigation; Non-compliance, systemic, DBHDS investigation; Non-compliance, systemic, DBHDS inve. Cited: 12VAC35-46-625. A. (7) The provider shall have and implement written policies and procedures for the on- site provision of a structured program of care or ...; 12VAC35-46-900. A. (3) Within 30 days of admission, the provider shall develop and implement a written behavior support plan that allows the resident to ...; 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;; 12VAC35-115-50. B. (2) In receiving all. "[...]" marks text left out between sentences.
The letter from DSS notes a Level 1 finding for the allegation of sexual abuse due to the following: Individual 1 remained fairly consistent with the disclosure made to Employee 3 and the Albemarle County Police Department detective regarding the sexual activity between Individual 1 and Employee 1. [...] Employee 4 reported rumors regarding Employee 1's sexual relationship with people at STARS previous to Individual 1's disclosure. [...] There is a preponderance of evidence to show Employee 1 sexually abused Individual 1. [...] Individual 1 had previously told Employee 2 about Individual 1's sexual relationship with Employee 1. [...] Employee 3 reported Individual 1 had told Employee 3 that Individual 1 had previously told Employee 2 about the sexual relationship with Employee 1.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.. "[...]" marks text left out between sentences.
A program reads every inspection report we collect and picks out findings that describe serious harm, using the state's own severity rating or complaint outcome where there is one. A person then reads the report and approves or rejects each one. Only findings the state substantiated are listed: a citation, or a complaint the investigator upheld. A child running away is listed only when it ended in a death or a serious injury. This page is not complete: it covers the states and reports reviewed so far, and a facility's absence here says nothing about its record. Every report we hold, flagged or not, is on the state trackers.