Inspection · 2023-09-12
Date
2023-09-12
Complaint Related
No
Licensing Inspector
Michelle Argenbright
(540) 848-4123
(540) 848-4123
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
8VAC20-780 Administration.
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
A renewal inspection was initiated on 09/12/2023 and concluded on 09/12/2023 from 1:29 PM to 3:45 PM. There were 26 children present, ranging in ages from two to six, with nine staff. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies. A total of five children?s records, the five staff?s records and three board officer?s records were reviewed.
Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the facility.
Violations
11Standard 22.1-289.035-B-2
Based on record review and interview, the center failed to obtain fingerprint results prior to the first day of employment.
Evidence:
1. The record for staff 2 documents the first day of employment as 8/28/23. The fingerprint results are dated 9/13/23.
2. Staff 6 verified the date of employment and date of fingerprint results.
Evidence:
1. The record for staff 2 documents the first day of employment as 8/28/23. The fingerprint results are dated 9/13/23.
2. Staff 6 verified the date of employment and date of fingerprint results.
Plan of Correction: Do not allow staff to start until fingerprint results are obtained.
Standard 22.1-289.036-B-2
Based on interviews, the center failed to obtain fingerprint background checks prior to the first day of service for two out of three agents of the center.
Evidence:
1. Staff 6 was unable to provide fingerprint results for board officer 1. Staff 6 stated board officer 1 started as a board officer on 9/23/21.
2. Board officer 3's fingerprint results are dated 11/5/21.
3. Staff 6 stated board officer 3 started as a board officer on 9/23/21.
Evidence:
1. Staff 6 was unable to provide fingerprint results for board officer 1. Staff 6 stated board officer 1 started as a board officer on 9/23/21.
2. Board officer 3's fingerprint results are dated 11/5/21.
3. Staff 6 stated board officer 3 started as a board officer on 9/23/21.
Plan of Correction: All paperwork for board members must be received prior to them starting a position.
Standard 8VAC20-770-40-D-1-a
Based on record review and interview, the center failed to have an agent of the center sign a sworn disclosure statement prior to the first day of service and have a completed central registry record check by the end of the 30th day of service.
Evidence:
1. Staff 6 stated board officer 1 has not completed a sworn disclosure statement and has not completed a central registry record check.
2. Staff 6 stated board officer 1 started as a board officer on 9/23/21.
3. Board officer 3 completed the sworn statement on 11/4/21 and the central registry findings were dated 12/28/21.
4. Staff 6 stated board officer 3 started as a board officer on 9/23/21.
Evidence:
1. Staff 6 stated board officer 1 has not completed a sworn disclosure statement and has not completed a central registry record check.
2. Staff 6 stated board officer 1 started as a board officer on 9/23/21.
3. Board officer 3 completed the sworn statement on 11/4/21 and the central registry findings were dated 12/28/21.
4. Staff 6 stated board officer 3 started as a board officer on 9/23/21.
Plan of Correction: All paperwork for board members must be received prior to them starting a position.
Standard 8VAC20-780-210-A
Based on record review and interview, the center failed to ensure two out of five staff met one of the requirements to be a program leader.
Evidence:
1. Staff 2 was observed alone with children on the playground. The record for staff 2 was reviewed. The record did not contain documentation of an education requirement to meet program leader qualifications.
2. Staff 6 stated staff 2 does not have the educational requirements to meet program leader qualifications.
3. Staff 6 stated staff 4 was the lead teacher downstairs in the afternoon.
4. The record for staff 4 did not contain documentation showing staff 4 meets the educational requirements to be a program leader.
5. Staff 6 verified staff 4 does not have the educational requirements to meet program leader qualifications.
Evidence:
1. Staff 2 was observed alone with children on the playground. The record for staff 2 was reviewed. The record did not contain documentation of an education requirement to meet program leader qualifications.
2. Staff 6 stated staff 2 does not have the educational requirements to meet program leader qualifications.
3. Staff 6 stated staff 4 was the lead teacher downstairs in the afternoon.
4. The record for staff 4 did not contain documentation showing staff 4 meets the educational requirements to be a program leader.
5. Staff 6 verified staff 4 does not have the educational requirements to meet program leader qualifications.
Plan of Correction: Staff records will reflect program leader requirements and files will be checked twice a month.
Standard 8VAC20-780-280-B
Based on observation, the center failed to ensure hazardous substances such as cleaning materials are kept in a locked place using a safe locking method that prevents access by children.
Evidence:
1. In the upstairs classroom an unlabeled bottle of Steramine sanitizer was on an open shelf out of reach of children. Staff 6 verified the bottle contained Steramine.
2. In the downstairs classroom a spray bottle of Goo Gone was on an open shelf out of reach of children.
Evidence:
1. In the upstairs classroom an unlabeled bottle of Steramine sanitizer was on an open shelf out of reach of children. Staff 6 verified the bottle contained Steramine.
2. In the downstairs classroom a spray bottle of Goo Gone was on an open shelf out of reach of children.
Plan of Correction: All spray bottles with hazardous substances are to be kept locked. Admin will check this 1X/week.
Standard 8VAC20-780-280-G
Based on observation, the center failed to keep a hazardous substance that was not in its original container in a container that is clearly labeled indicating its contents.
Evidence:
1. In the upstairs classroom a clear spray bottle was on an open shelf with no label of its contents.
2. Staff 6 stated the bottle contained the sanitizer Steramine and should have been labeled.
Evidence:
1. In the upstairs classroom a clear spray bottle was on an open shelf with no label of its contents.
2. Staff 6 stated the bottle contained the sanitizer Steramine and should have been labeled.
Plan of Correction: All bottles will be labeled and stored according to their contents. Locked up mostly.
Standard 8VAC20-780-510-F
Based on interview, the center failed to maintain a medication authorization for two medications at the center.
Evidence;
1. In the upstairs classroom a tube of Cortizone and itch relief cream was on a shelf.
2. Staff 6 stated both creams belong to children in care and the center did not have medication authorizations for either medication.
Evidence;
1. In the upstairs classroom a tube of Cortizone and itch relief cream was on a shelf.
2. Staff 6 stated both creams belong to children in care and the center did not have medication authorizations for either medication.
Plan of Correction: Parents were given forms to complete and returned them correctly completed. All meds go to lock box in the office or refrigerator.
Standard 8VAC20-780-510-G
Based on observation and interview, the center failed to label medication with the dosage amount and times to be given.
Evidence:
1. In the upstairs classroom a tube of Cortizone and Itch relief ointment was found. Neither product was labeled with the dosage and time to be given.
2. Staff 6 verified both creams were for children in care.
Evidence:
1. In the upstairs classroom a tube of Cortizone and Itch relief ointment was found. Neither product was labeled with the dosage and time to be given.
2. Staff 6 verified both creams were for children in care.
Plan of Correction: No meds will be received by the school unless proper completed paperwork is present.
Standard 8VAC20-780-510-L
Based on observation, the center failed to keep medication in a locked location using a safe locking method that prevents access by children.
Evidence:
1. In the upstairs classroom, on a high shelf, was a tube of Cortizone and itch relief cream.
2. Staff 6 verified both medications belonged to children in care.
Evidence:
1. In the upstairs classroom, on a high shelf, was a tube of Cortizone and itch relief cream.
2. Staff 6 verified both medications belonged to children in care.
Plan of Correction: Medicine moved to lock box.
Standard 8VAC20-780-510-N
Based on interview, the center did not keep a record of medication given to children.
Evidence:
A tube of Cortizone and Itch Relief Cream was found in the upstairs classroom. Staff 6 verified the over-the-counter medications were for children and both had been administered a few times. No documentation had been completed for either medication.
Evidence:
A tube of Cortizone and Itch Relief Cream was found in the upstairs classroom. Staff 6 verified the over-the-counter medications were for children and both had been administered a few times. No documentation had been completed for either medication.
Plan of Correction: All medications are now stored in the front office with the log binder.
Standard 8VAC20-780-530-A
Based on record review and observation, the center failed to ensure at least one staff in each classroom or area where children are present has a current certification in CPR & first aid.
Evidence:
1. Staff 2 was alone outside with children. The record for staff 2 did not contain a certification in CPR & first aid.
2. Staff 4 was alone with children during nap in the main space downstairs. The record for staff 4 did not contain a certification in CPR & first aid.
3. Staff 6 verified staff 2 and staff 4 do not have certification in CPR & first aid.
Evidence:
1. Staff 2 was alone outside with children. The record for staff 2 did not contain a certification in CPR & first aid.
2. Staff 4 was alone with children during nap in the main space downstairs. The record for staff 4 did not contain a certification in CPR & first aid.
3. Staff 6 verified staff 2 and staff 4 do not have certification in CPR & first aid.
Plan of Correction: Staff 2 received CPR & First Aid training on 9/25/23. We will create a schedule to ensure there is always at least 1 staff member with the correct certificates with the children.