Inspection · 2021-04-23
Date
2021-04-23
Complaint Related
Yes
Licensing Inspector
Miranda Wright
(571) 596-3661
(571) 596-3661
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 SPECIAL CARE PROVISIONS AND EMERGENCIES.
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 complaint investigation was initiated on 4/23/21 and concluded on 5/7/21. A complaint was received by the department regarding allegations in the areas of ratios and illness. The director was contacted by telephone to conduct the investigation. 2 staff members were interviewed and a virtual walk through of the facility was conducted to assess if staff to children ratios were maintained. Child supervision records for various dates were reviewed. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law and violations were issued. For any questions regarding this inspection, please contact me at (571)-835-4718 or mahrukh.aziz@dss.virginia.gov.
Violations
3Standard 22VAC40-185-350-E-3
Based on records review, staff to children ratio of one staff to eight children was not maintained for two-year-old children.
Evidence:
1. A review of the Child Supervision Record (CSR) for the 2?s classroom dated 4/13/21 showed that:
a. From 8:56 am to 9:08 am, Staff # 1 was alone with 9 two year old children by herself.
b. At 9:08 am, 2 more children arrived, for a total of 12 children with one staff person (Staff # 1).
c. Staff #1 was alone with the 12 children until Staff # 2 signed in at 10:10 am.
2. A review of the CSR for the 2?s classroom dated 4/19/21 showed that:
a. From 8:50 am to 8:51 am, Staff # 1 was alone with 10 two year old children.
b. At 8:51 am, Staff # 1 was alone with 11 two year old children.
c. From 8:55am to 10:35 am, Staff # 1 was alone with 12 two year old children.
d. The class was out of ratio from 8:50 am to 10:35 am. Staff # 2 signed in at 10:35 am.
3. A review of the CSR for both the 2?s and Preschool (3 ?year old) classroom combined, dated
4/23/21 showed that:
a. From 7:45 am to 8:15 am, the ratio of 1 staff for every 8 children as required for the youngest child
in the group was not maintained; b. From 7:45 am to 7:57 am, Staff # 1 was alone with 9 children;
c. From 7:57 am to 8:15 am, Staff # 1 was alone with 10 children.
Evidence:
1. A review of the Child Supervision Record (CSR) for the 2?s classroom dated 4/13/21 showed that:
a. From 8:56 am to 9:08 am, Staff # 1 was alone with 9 two year old children by herself.
b. At 9:08 am, 2 more children arrived, for a total of 12 children with one staff person (Staff # 1).
c. Staff #1 was alone with the 12 children until Staff # 2 signed in at 10:10 am.
2. A review of the CSR for the 2?s classroom dated 4/19/21 showed that:
a. From 8:50 am to 8:51 am, Staff # 1 was alone with 10 two year old children.
b. At 8:51 am, Staff # 1 was alone with 11 two year old children.
c. From 8:55am to 10:35 am, Staff # 1 was alone with 12 two year old children.
d. The class was out of ratio from 8:50 am to 10:35 am. Staff # 2 signed in at 10:35 am.
3. A review of the CSR for both the 2?s and Preschool (3 ?year old) classroom combined, dated
4/23/21 showed that:
a. From 7:45 am to 8:15 am, the ratio of 1 staff for every 8 children as required for the youngest child
in the group was not maintained; b. From 7:45 am to 7:57 am, Staff # 1 was alone with 9 children;
c. From 7:57 am to 8:15 am, Staff # 1 was alone with 10 children.
Plan of Correction: Hire more staff: 2 new staff hired on 5/10/21. Training completed 2 new staff on-boarding Training completed. When classes are combined in one pod, teachers will use one CSR and notate on back under single/small group transition, time child is moved to another classroom and/or time child returns.
Standard 22VAC40-185-350-E-4
Based on records review and staff interview, the staff to children ratio of one staff to ten children was not maintained for children ages three years.
Evidence:
1. Staff # 3 stated that on 4/23/21, the Preschool classroom was out of ratio as three staff members
had ?called out?.
2. A review of the Preschool?s CSR dated 4/23/21 showed that from 8:35 am to 10:25 am, the ratio of
ten children to 1 staff was not maintained in the Preschool classroom: a. At 8: 35 am, Staff # 4 was alone with 13 children; b. At 8:40 am, Staff # 4 was alone with 14 children; c. At 8:50 am, Staff # 4 was alone with 15 children; d. At 8: 55 am, Staff # 4 was alone with 16 children; e. At 9:11 am, Staff # 4 was alone with 17 children; and f. At 9:50 am, Staff # 4 was alone with 18 children total until 10:25 am when Staff # 5 returned from bus runs and signed in.
Evidence:
1. Staff # 3 stated that on 4/23/21, the Preschool classroom was out of ratio as three staff members
had ?called out?.
2. A review of the Preschool?s CSR dated 4/23/21 showed that from 8:35 am to 10:25 am, the ratio of
ten children to 1 staff was not maintained in the Preschool classroom: a. At 8: 35 am, Staff # 4 was alone with 13 children; b. At 8:40 am, Staff # 4 was alone with 14 children; c. At 8:50 am, Staff # 4 was alone with 15 children; d. At 8: 55 am, Staff # 4 was alone with 16 children; e. At 9:11 am, Staff # 4 was alone with 17 children; and f. At 9:50 am, Staff # 4 was alone with 18 children total until 10:25 am when Staff # 5 returned from bus runs and signed in.
Plan of Correction: New staff hired effective 5/10/2 Teachers have been re-trained on ensuring everyone signs in on the CSR and it is accurate.
Standard 22VAC40-185-40-E
Based on records review and staff interview, the center did not follow its own policies and procedures that are required by the standards.
Evidence:
1. The center?s policies for the Child Supervision Records include: a. ?The CSR is an attendance taking system designed to establish accountability for all children in care; and provide program(classroom) specific attendance?; and b. ?Staff members responsible for the children must keep the CSR accurate and current at all times?.
2. The 2?s classroom CSR dated 4/13/21, showed that Child # 1?s time in was 7:13 am. Staff # 1 was the first staff to sign in on this CSR at 7:30 am. It was unclear which staff was accountable for Child # 1 from 7:13 am to 7:30 am.
3. The 2?s classroom CSR dated 4/13/21 was missing entries for ?total number of children?, ?total number of teachers?, and the ?teacher?s initials? for the ?Name to Face Transitions? at 4:30 pm.
4. Written documentation from Staff # 3 on the Preschool classroom CSR dated 4/19/21 shows that Staff # 1 did not sign in from 7:02 am to 7:30 am. Staff # 1 was the responsible staff for both the 2?s and Preschool classrooms during this time.
5. The CSR for the Preschool class dated 4/20/21 showed that: a. Staff # 6 signed out at 12:00 pm under the ?Teacher/Staff Attendance? section. However, on the following line Staff # 6 did not document her time in for when she returned. b. Staff # 4 did not document her time out for the day.
6. On 4/23/21, the CSR for the 2?s classroom showed that Child # 3 and Child # 4 were transitioned to Preschool 3 at 9:11 am and 9:02 am respectively. However, on the CSR for the Preschool room, Staff # 3 made written documentation that they were not signed in for this transition.
7. On 4/23/21, Staff # 3 made a note under ?Teacher/Staff Attendance? that Staff # 6 ?forgot to sign in @ 10:25 am?. Staff # 6?s sign in was documented by Staff # 3 at a later time.
Evidence:
1. The center?s policies for the Child Supervision Records include: a. ?The CSR is an attendance taking system designed to establish accountability for all children in care; and provide program(classroom) specific attendance?; and b. ?Staff members responsible for the children must keep the CSR accurate and current at all times?.
2. The 2?s classroom CSR dated 4/13/21, showed that Child # 1?s time in was 7:13 am. Staff # 1 was the first staff to sign in on this CSR at 7:30 am. It was unclear which staff was accountable for Child # 1 from 7:13 am to 7:30 am.
3. The 2?s classroom CSR dated 4/13/21 was missing entries for ?total number of children?, ?total number of teachers?, and the ?teacher?s initials? for the ?Name to Face Transitions? at 4:30 pm.
4. Written documentation from Staff # 3 on the Preschool classroom CSR dated 4/19/21 shows that Staff # 1 did not sign in from 7:02 am to 7:30 am. Staff # 1 was the responsible staff for both the 2?s and Preschool classrooms during this time.
5. The CSR for the Preschool class dated 4/20/21 showed that: a. Staff # 6 signed out at 12:00 pm under the ?Teacher/Staff Attendance? section. However, on the following line Staff # 6 did not document her time in for when she returned. b. Staff # 4 did not document her time out for the day.
6. On 4/23/21, the CSR for the 2?s classroom showed that Child # 3 and Child # 4 were transitioned to Preschool 3 at 9:11 am and 9:02 am respectively. However, on the CSR for the Preschool room, Staff # 3 made written documentation that they were not signed in for this transition.
7. On 4/23/21, Staff # 3 made a note under ?Teacher/Staff Attendance? that Staff # 6 ?forgot to sign in @ 10:25 am?. Staff # 6?s sign in was documented by Staff # 3 at a later time.
Plan of Correction: CSR re-training completed except for Staff #1 and Staff #2. Staff #1 is not working here and Staff #2 is on medical leave. Staff #2 was re-trained individually and reviewed her CS to ensure she was signing in/out correctly each time and when a child was transitioned. Teachers have been observed completing the CSR to ensure they are correct. Teachers have been instructed to use one CSR when a POD is together. Teachers will write child 's name back under "Single/small group transition" where child is going, time out and time returns. Teachers are given walkie-talkies to call immediately when they are at their max for ratio. Teacher Schedules have been adjusted so two teachers are in the classroom to maintain ratio.