Inspection · 2024-08-15
Date
2024-08-15
Complaint Related
No
Licensing Inspector
Maria Robles-Lopez
(703) 397-3827
(703) 397-3827
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
An unannounced, on-site monitoring inspection was conducted on 08/15/2024 as a part of the licensure period. The inspector reviewed compliance in the areas listed above. There were 34 children present and 7 staff.
The inspector reviewed 5 children?s records and 3 staff records on-site. Some additional information was provided electronically on 08/16/2024. This inspection included document review (i.e. Injury logs, policies and procedures, emergency drill logs, medication administration logs, authorization forms), tour of the facility, and interviews.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within 5 business days from today, which will be the close of business on 09/05/2024. A POC submitted after this date will not appear on the public website.
Violations
14Standard 22.1-289.035-B-1
Based on record review and interview, the center did not ensure to obtain a completed Sworn Statement prior to first day of employment.
Evidence:
1) On the date of inspection, the record for Staff #1 (start date 07/29/2024) did not contain a completed Sworn Statement.
Evidence:
1) On the date of inspection, the record for Staff #1 (start date 07/29/2024) did not contain a completed Sworn Statement.
Plan of Correction: Staff #1 completed a sworn statement on 08/16/2024. Moving forward, all staff will be required to provide all documentation before their start date.
Standard 22.1-289.035-B-3
Based on record review, it was determined that the center did not ensure that Central Registry search results were requested prior to the first date of employment.
Evidence:
1) On the date of inspection, the record for Staff #1 (start date 07/29/2024) did not contain documentation that a CRS request was made prior to
the date of employment.
Evidence:
1) On the date of inspection, the record for Staff #1 (start date 07/29/2024) did not contain documentation that a CRS request was made prior to
the date of employment.
Plan of Correction: Staff #1 file has been updated with a copy of their CRS results. Moving forward the center will ensure all staff be required to provide all documentation before their start date.
Standard 22.1-289.035-B-4
Based on record review and interview, it was determined that the center did not ensure that employees that had lived out of the state of VA within the last 5 years have in their files documentation that an out-of-state Central Registry search request, and an out-of-state Sex Offender Registry search request were requested prior to the first date of employment.
Evidence:
1) The record for Staff #3 (start date 07/30/2024) did not contain documentation that an out-of-state Central Registry search request, and an out-of-state Sex Offender Registry search request had been requested. Staff #3 had declared in their sworn statement having lived out of the state of VA within the last 5 years before employment.
Evidence:
1) The record for Staff #3 (start date 07/30/2024) did not contain documentation that an out-of-state Central Registry search request, and an out-of-state Sex Offender Registry search request had been requested. Staff #3 had declared in their sworn statement having lived out of the state of VA within the last 5 years before employment.
Plan of Correction: Staff #3 has completed the required background checks needed for out-of-state. Moving forward, staff that have lived out of state within 5 years will be required to conduct out-of-state Central Registry and Sexual offender searches.
Standard 22.1-289.058
Based on interview with the program director, the center is not equipped with at least one carbon monoxide detector.
Evidence:
1) The program director stated that the center is not equipped with a carbon monoxide detector.
Evidence:
1) The program director stated that the center is not equipped with a carbon monoxide detector.
Plan of Correction: Center has been equipped with a carbon monoxide monitor.
Standard 8VAC20-780-160-A
Based on record review, the center did not ensure that documentation of negative tuberculosis (Tb) screening for each employee was submitted at the time of employment and prior to coming into contact with children.
Evidence:
1) The record for Staff #1 (start date 07/29/2024) did not contain a Tb screening.
Evidence:
1) The record for Staff #1 (start date 07/29/2024) did not contain a Tb screening.
Plan of Correction: Staff #1 provided documentation of a negative Tb test on 08/23/24, and it has been added to their file. Staff will be required to provide documentation of a negative Tb screening prior to their fist day of employment.
Standard 8VAC20-780-240-B
Based on record review, staff did not complete required orientation training prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
Evidence:
1) The record for Staff #1 (start date 07/29/2024) did not contain documentation that the employee completed orientation training as required.
Evidence:
1) The record for Staff #1 (start date 07/29/2024) did not contain documentation that the employee completed orientation training as required.
Plan of Correction: Staff #1 has completed the required orientation, and the documentation has been added to her file. Center will ensure that staff members are given the required state orientation documentation.
Standard 8VAC20-780-240-C
Based on record review, staff's orientation training did not include all required topics.
Evidence:
1) The orientation training log in the record for Staff #3 did not contain documentation that staff had been trained in the following, as required: the center's playground safety procedures; confidential treatment of personal information about children in care and their families; and prevention of and response to emergencies due to food and other allergic reactions.
Evidence:
1) The orientation training log in the record for Staff #3 did not contain documentation that staff had been trained in the following, as required: the center's playground safety procedures; confidential treatment of personal information about children in care and their families; and prevention of and response to emergencies due to food and other allergic reactions.
Plan of Correction: Center will ensure required orientation will include required topics such as but not limited to playground safety procedures, confidential treatment of personal information of children and families, and response to food and other allergic reactions.
Standard 8VAC20-780-240-D
Based on record review, the center did not ensure that staff be provided in writing with the center's information listed in 8VAC20-780-420 A and other required information.
Evidence:
1) The records for Staff #1 and Staff #3 did not contain documentation of having received in writing the required information listed in 8VAC20-780-240-D.
Evidence:
1) The records for Staff #1 and Staff #3 did not contain documentation of having received in writing the required information listed in 8VAC20-780-240-D.
Plan of Correction: Staff members #1 and #3 were given the required information on LCG policy and procedures. Moving forward, staff members will be provided with the information during orientation.
Standard 8VAC20-780-260-A
Based on documentation review, the center did not provide to the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction.
Evidence:
1) On the date of inspection, the most recent inspection report available for review was dated 08/12/2022.
Evidence:
1) On the date of inspection, the most recent inspection report available for review was dated 08/12/2022.
Plan of Correction: Documentation has been received for prior inspections and an inspection has been requested. Moving forward inspections will be scheduled 60 days prior to the due date to ensure they are completed in a timely manner.
Standard 8VAC20-780-270-A
Based on observation, areas and equipment of the center were not maintained in a clean, safe and operable condition.
Evidence:
1) A loose air conditioner vent cover was observed in the Two's classroom. The vent cover was not attached to the wall on the upper right corner.
2) A play floor mat area in the Two's classroom looked dirty.
3) Two blue tricycles on the playground were observed to have areas of peeling paint and had rust exposed.
3) An infant buggy that is used daily to take the children outside, showed with visible signs of dirt and the fabric for the seats looked dirty.
Evidence:
1) A loose air conditioner vent cover was observed in the Two's classroom. The vent cover was not attached to the wall on the upper right corner.
2) A play floor mat area in the Two's classroom looked dirty.
3) Two blue tricycles on the playground were observed to have areas of peeling paint and had rust exposed.
3) An infant buggy that is used daily to take the children outside, showed with visible signs of dirt and the fabric for the seats looked dirty.
Plan of Correction: Facility items listed in 1-4 have been corrected. Moving forward, work orders will be submitted as needed for facility repairs. Play mats will be deep cleaned weekly to ensure cleanliness. Daily checks of the equipment will ensure that outside toys will be removed if they have rust or chipped paint. The infant buggy will be power washed as needed and spot cleaned as needed and sanitized weekly.
Standard 8VAC20-780-420-E-3
Based on record review, the center did not request at least annually parent confirmation that the required information in the child's record is up to date.
Evidence:
1) The most recent review of the emergency information documented in the record for Child #5 was dated 07/13/2021.
Evidence:
1) The most recent review of the emergency information documented in the record for Child #5 was dated 07/13/2021.
Plan of Correction: Management has scheduled an annual update of all child files on 09/06/2024.Moving forward, management has scheduled annual updates to ensure compliance.
Standard 8VAC20-780-550-P
Based on a review of 10 injury reports, it was determined that the facility did not ensure that the written record of children's serious and minor injuries includes all of the required information.
Evidence:
1) Four of the10 injury reports reviewed did not include the date and time when parents were notified.
2) Three of the 10 injury reports reviewed did not include one or two of the required signatures.
Evidence:
1) Four of the10 injury reports reviewed did not include the date and time when parents were notified.
2) Three of the 10 injury reports reviewed did not include one or two of the required signatures.
Plan of Correction: Staff will be retrained to ensure that injury reports are completed correctly.
Standard 8VAC20-780-60-A
Based on records review, children's records did not contain all required information.
Evidence:
1) The record for Child #1 did not contain the name, address and phone number of an additional person to contact in case of an emergency; the work phone number of both custodial parents; and the first date of attendance.
Evidence:
1) The record for Child #1 did not contain the name, address and phone number of an additional person to contact in case of an emergency; the work phone number of both custodial parents; and the first date of attendance.
Plan of Correction: Child #1 file has been updated with emergency contacts, parent phone numbers, and start date. Moving forward, students will be required to have all required documentation before their start date.
Standard 8VAC20-780-70
*REPEAT VIOLATION*
Based on record review, staff's records did not contain all required information.
Evidence:
1) The records for Staff #1, Staff #2 and Staff #3 did not contain the following: name, address, and telephone number of a person to be notified in an emergency which shall be kept at the center; and information, to be kept at the center, about any health problems that may interfere with fulfilling the job responsibilities;
2) The record for Staff #1 (start date 07/29/2024) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
Based on record review, staff's records did not contain all required information.
Evidence:
1) The records for Staff #1, Staff #2 and Staff #3 did not contain the following: name, address, and telephone number of a person to be notified in an emergency which shall be kept at the center; and information, to be kept at the center, about any health problems that may interfere with fulfilling the job responsibilities;
2) The record for Staff #1 (start date 07/29/2024) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
Plan of Correction: Staff #1, 2, and 3 have completed the contact forms and health questionnaire for their files. Staff #1 had the required reference check completed that included 2 references. Moving forward, all staff will be required to provide all documentation before their first day.