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Mount Calvary Lutheran Church

Inspection · 2024-09-10

Date
2024-09-10
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.
Yes

Areas Reviewed

8VAC20-770 Background Checks
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services

Inspector Notes

A Subsidy Health and Safety inspection was conducted on September 10, 2024 to review supplemental health and safety requirements. This on-site visit was conducted from 11:50 am through 1:00 pm. Upon arrival, there were 31 children, ages from 6 months through 5, with 9staff supervising. Five children records and eight staff records were reviewed and updated.

Areas of non-compliance may be found on the violation notice.

Please complete your plan of correction and return to the licensing inspector within 5 business days.

Violations

6
Standard 22.1-289.035-B-1
Based on record review the facility failed to obtain a sworn statement for one employee prior to employment.

Evidence:

1. Staff #8 did not have documentation of a sworn statement prior to employment. Date of hire was documented 4.8.2024.
2. Administration confirmed a sworn statement was not obtained.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-560-A
Based on record review the facility failed to obtain a tuberculosis screening for one staff member within 30 days prior to employment.

Evidence:

1. Staff # 8 did not have documentation of obtaining a tuberculosis screening with 30 days prior to employment. Date of hire was documented 4.8.2024.
2. Administration confirmed there was no documentation for Staff #8 obtaining a tuberculosis screening.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-560-B
Based on record review the facility failed to have seven staff members obtain an updated tuberculosis screening.

Evidence:

1. Staff # 1,2,3,4,5,6,and 7 did not have documentation of obtaining an updated tuberculosis screening.
2. Administration confirmed an tuberculosis screening had not been obtained.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-D-1
Based on record review the facility failed to obtain CPR training within 90 days of hire date.

Evidence:

1. Staff #9 did not have documentation of obtaining CPR within 90 days of hire. Date of hire was documented 11.20.2023.
2. Staff confirmed no documentation of CPR was on file.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-D-2
Based on record review the facility failed to obtain first aid training within 90 days of hire date.

Evidence:

1. Staff #9 did not have documentation of obtaining first aid within 90 days of hire. Date of hire was documented 11.20.2023.
2. Staff confirmed no documentation of first aid training was on file.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-F
Based on record review the facility failed to have four staff members complete the department's health and safety update course.

Evidence:
1. Staff #'s 2, 3, 4 and 5 did not have documentation of completing the departments annual 3- hour health and safety update course.
2. Administration confirmed these staff had not completed the annual 3-hour updated course.
Plan of Correction: Not available online. Contact Inspector for more information.