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Main Street Day Care Center, Inc.

Inspection · 2021-05-03

Date
2021-05-03
Complaint Related
No
Licensing Inspector
Anita Drewry
(757) 404-5261
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
No

Areas Reviewed

22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
22VAC40-80 SANCTIONS.
22VAC40-80 HEARINGS PROCEDURES.
22VAC40-191 Background Checks (22VAC40-191)
20 Access to minor?s records
32.1 Report by person other than physician
63.2 Child Abuse & Neglect
63.2(17) License & Registration Procedures
63.2 Facilities & Programs.

Inspector Notes

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 5/3/2021 and concluded on 5/11/2021. The director was contacted by telephone to initiate the inspection. There were 88 children present and 17 staff. The inspector emailed the director/provider a list of items required to complete the inspection. The Inspector reviewed 5 children?s records and 5 staff records submitted by the facility to ensure documentation was complete.

Information gathered during the inspection determined non-compliance(s) with applicable standards or law and violations were documented on the violation notice issued to the facility.

Violations

5
Standard 22VAC40-185-260-A
Based on a review of documentation and interview, the licensee was unable to demonstrate that an annual fire inspection had been conducted.
Evidence:
The licensing inspector requested a copy of the most recent fire inspection conducted at the center.
The program director was not able to produce documentation of a fire inspection conducted at the center.
She has recently been hired as the program director and cannot locate this document.
Plan of Correction: The program director will try to locate the report and if she is unable to locate it she will contact the fire Marshall to request a duplicate or to schedule a new inspection depending on when the last inspection was conducted.
Standard 22VAC40-185-260-B
Based on a review of documentation and interview, the licensee was unable to demonstrate that an annual health inspection had been conducted.
Evidence:
The licensing inspector requested a copy of the most recent health inspection conducted at the center.
The most recent health inspection that the program director was able to produce was dated 1/7/2019.
She has recently been hired as the program director and is unsure of whether a more recent inspection has been conducted.
Plan of Correction: The program director will contact the local health department to request a duplicate of the most recent inspection or to schedule a new inspection depending on when the last inspection was conducted.
Standard 22VAC40-185-70-A
Based on a review of documentation and interview, the licensee did not maintain a complete staff record for each employed staff which contains all of the required documentation.

Evidence:
The records submitted for staff #1, #4 and #5 did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
The records for staff #2 and staff #3 contained a few brief notes indicating that a call had been made but did not contain all of the required information from the reference checks that were completed before their employment in the program.
Plan of Correction: The program director will ensure that references are checked prior to hiring new staff and if references are taken over the phone, that the following information is documented:
Dates of contact; Names of persons contacted; The firms contacted; Results; and Signature of person making call.
Standard 22VAC40-191-60-C-2
Based on a review of documentation and interview, the licensee was unable to demonstrate that a central registry finding has been obtained for every staff within 30 days of their employment or volunteer service.

Evidence:
The records for 5 staff were requested.
Four of the 5 staff records requested did not contain the results of a Search of the Central Registry (staff #1 hired 3/18/2021, staff #2 hired 7/1/19, staff #4 hired 2/15/2021 and staff #5 hired 3/15/2021).
The program director was unable to locate documentation of the central registry findings for the 4 staff.
She has recently been promoted to Program Director and is still trying to locate various missing documentation.
Plan of Correction: The program director will attempt to locate the missing central registry reports and contact the agency to request duplicates. Any staff for whom she is unable to obtain the documentation for will have another Search of the Central Registry requested within 10 days.
Standard 63.2(17)-1720.1-B-4
Based on a review of documentation and interview, the licensee was not able to demonstrate that an out of state Sex Offender Registry and out of state Child Abuse and Neglect registry was requested by the End of staff's 30th day of employment for staff any who resided outside of the state of Virginia in the past 5 years.
Evidence:
Five staff records were reviewed.
The records for staff #1 (hired 3/18/21), staff #2 (hired 7/1/19) and staff #4 (hired 2/15/2021) all indicated on their signed sworn disclosure statement that they had lived in the state of North Carolina within the past 5 years.
The licensee was not able to demonstrate that an out of state Child Abuse and Neglect Registry nor an out of state Sex Offender Registry search had been obtained by the end of staff #1, staff #2, and staff #4's 30th Day of Employment.
Plan of Correction: The program director was unsure if this documentation had been obtained by the previous director, but was unable to locate documentation of the requests or the results of these background checks during the inspection.
She will continue to try to locate this documentation and will contact the appropriate agencies to request duplicates if they have been conducted. If unable to obtain the results, she will send requests for new out of state Child Abuse and Neglect as well as out of state Sex Offender Registry searches within 10 days and send this documentation to her licensing inspector at that time.
View original record on Virginia Department of Social Services