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Mount Calvary Lutheran Church

Inspection · 2021-04-30

Date
2021-04-30
Complaint Related
No
Licensing Inspector
Kelly Lindsay
(540) 309-2494
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

32.1 Report by person other than physician
54.1-3408 Must be MAT Certified.
63.2 Child Abuse & Neglect
63.2(17) License & Registration Procedures
63.2 Facilities & Programs.
22VAC40-191 Background Checks for Child Welfare Agencies

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 code compliance inspection was initiated on April 21, 2021 and concluded on April 28, 2021. The director was contacted by telephone to initiate the inspection. There were (71) children present and (14) staff. The inspector emailed the director a list of items required to complete the inspection. The Inspector reviewed (4) staff records submitted by the facility to ensure documentation was complete.

Information gathered during the inspection determined non-compliance with applicable code sections and violations were documented on the violation notice issued to the facility.

The Licensing Inspector has reviewed with the provider COVID-19 Essential Guidance for Child Care programs.

Please contact the licensing inspector at 540-430-9256 if you have any questions.

Violations

2
Standard 22VAC40-191-40-D-2
Based on record review, the facility failed to obtain a central registry search within 20 days of employment for two staff.

Evidence:

1. Thirteen staff records were reviewed and updated.
2. Staff # 3 and #4 did not have documentation of a central registry check in the state of Virginia within
30 days of hire.
3. The director confirmed Staff #3 and Staff #4 had not had a central registry check completed in the
state of Virginia.
Plan of Correction: Virginia central registry checks for Staff #3 and Staff #4 were completed and mailed on April 27, 2021. Documentation will be provided to the licensing inspector once results are received.
Standard 63.2(17)-1720.1-A
Based on record review, the facility failed to obtain a repeat central registry check for one employee.

Evidence:

1. Thirteen staff records were reviewed.
2. Staff #10 did not have documentation of a repeated Virginia central registry check being obtained within five years of the prior date.
3. Last documentation of Virginia central registry check was dated 03/01/2016.
4. The director confirmed the repeat check had not been completed.
Plan of Correction: A Virginia central registry check was completed and mailed for Staff #10 on April 27, 2021. Documentation of results will be sent to the licensing inspector.
View original record on Virginia Department of Social Services