Inspection · 2022-07-20
Date
2022-07-20
Complaint Related
No
Licensing Inspector
D'Nae Goodwin
(757) 404-3063
(757) 404-3063
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.
8VAC20-770 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 monitoring inspection was conducted on 7/20/22 from 10:30am - 1:00pm. During the inspection there were 84 children ages five years old through twelve years old in care with 11 staff. Children were observed participating in various activities in the classrooms, playing outside, swimming, and eating lunch. Records were reviewed for ten children and eleven staff during the inspection. Medication, emergency procedures and emergency supplies were reviewed during the inspection. Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the program, and were discussed during the exit interview.
Violations
7Standard 8VAC20-770-60-C-2
Based on a review of eleven staff records, it was determined that the facility did not deny continued employment of a staff who did not have a search of the central registry finding
within 30 days of employment.
Evidence:
1. The record for staff #1 (date of hire 6/10/22) did not contain documentation of a completed
search of the central registry finding.
2. The record for staff #2 (date of hire 6/7/22) did not contain documentation of a completed
search of the central registry finding.
3. The record for staff #4 (date of hire 5/17/22) did not contain documentation of a completed
search of the central registry finding.
4. The record for staff #5 (date of hire 6/14/22) did not contain documentation of a completed
search of the central registry finding.
5. The record for staff #6 (date of hire 6/10/22) did not contain documentation of a completed
search of the central registry finding.
6. The record for staff #7 (date of hire 6/10/22) did not contain documentation of a completed
search of the central registry finding.
7. The record for staff #8 (date of hire 6/15/22) did not contain documentation of a completed
search of the central registry finding.
8. The record for staff #9 (date of hire 6/13/22) did not contain documentation of a completed
search of the central registry finding.
9. The record for staff #10 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding.
10. Staff #p11 (Program Director) reviewed the records for the staff listed above, and confirmed that the search of the central registry finding has not been received.
within 30 days of employment.
Evidence:
1. The record for staff #1 (date of hire 6/10/22) did not contain documentation of a completed
search of the central registry finding.
2. The record for staff #2 (date of hire 6/7/22) did not contain documentation of a completed
search of the central registry finding.
3. The record for staff #4 (date of hire 5/17/22) did not contain documentation of a completed
search of the central registry finding.
4. The record for staff #5 (date of hire 6/14/22) did not contain documentation of a completed
search of the central registry finding.
5. The record for staff #6 (date of hire 6/10/22) did not contain documentation of a completed
search of the central registry finding.
6. The record for staff #7 (date of hire 6/10/22) did not contain documentation of a completed
search of the central registry finding.
7. The record for staff #8 (date of hire 6/15/22) did not contain documentation of a completed
search of the central registry finding.
8. The record for staff #9 (date of hire 6/13/22) did not contain documentation of a completed
search of the central registry finding.
9. The record for staff #10 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding.
10. Staff #p11 (Program Director) reviewed the records for the staff listed above, and confirmed that the search of the central registry finding has not been received.
Plan of Correction: The facility responded: All staff have requested a search of the central registry, but we will check the status and forward to the Licensing Inspector when complete.
Standard 8VAC20-780-140-A
Based on a review of ten children's records, it was determined that the facility did not ensure that each child in attendance had a completed physical within one month of attendance.
Evidence:
1. The record for child #2 did not contain a physical examination.
2. The record for child #7 did not contain a physical examination.
3. Staff #11 (Program Director) confirmed that the record for child #2 and child #7 did not
contain a physical examination, and had been enrolled for more than 30 days.
Evidence:
1. The record for child #2 did not contain a physical examination.
2. The record for child #7 did not contain a physical examination.
3. Staff #11 (Program Director) confirmed that the record for child #2 and child #7 did not
contain a physical examination, and had been enrolled for more than 30 days.
Plan of Correction: The facility responded: The parents of each child will be asked to provide the
missing physical examination.
missing physical examination.
Standard 8VAC20-780-160-A
Based on a review of eleven staff records, it was determined that the facility did not ensure that each staff member shall submit documentation of a negative tuberculosis screening prior to employment beginning..
Evidence:
1. The record for child #2 did not contain a physical examination.
2. The record for child #7 did not contain a physical examination.
3. Staff #11 (Program Director) confirmed that the record for child #2 and child #7 did not
contain a physical examination, and had been enrolled for more than 30 days.
Evidence:
1. The record for child #2 did not contain a physical examination.
2. The record for child #7 did not contain a physical examination.
3. Staff #11 (Program Director) confirmed that the record for child #2 and child #7 did not
contain a physical examination, and had been enrolled for more than 30 days.
Plan of Correction: The facility responded: Staff will be sent to complete a TB screening. All
new staff will complete a TB screening prior to employment.
new staff will complete a TB screening prior to employment.
Standard 8VAC20-780-290-A-3
Based on observation and interview, it was determined that the facility did not ensure that
electrical outlets shall have protective covers that are of a size that cannot be swallowed by
children.
Evidence:
1. There were uncovered electrical outlets throughout the entire facility.
2. Staff #11 (Program Director) confirmed that the electrical outlets did not have protective
covers.
electrical outlets shall have protective covers that are of a size that cannot be swallowed by
children.
Evidence:
1. There were uncovered electrical outlets throughout the entire facility.
2. Staff #11 (Program Director) confirmed that the electrical outlets did not have protective
covers.
Plan of Correction: The facility responded: We will cover all electrical outlets with protective coverings.
Standard 8VAC20-780-340-D
Based on observation, a review of five staff records and interviews, it was determined that
the licensee did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present.
Evidence:
1. Staff #3, staff #5, and staff #8 were working with a group of School Age children outside. The records for all three staff did not contain documentation to demonstrate that any of the staff were Program Leader qualified.
2. Staff #11 (Program Director) reviewed the records for the staff listed above, and confirmed that was documentation available for viewing during the inspection that any of the staff were Program Leader qualified.
the licensee did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present.
Evidence:
1. Staff #3, staff #5, and staff #8 were working with a group of School Age children outside. The records for all three staff did not contain documentation to demonstrate that any of the staff were Program Leader qualified.
2. Staff #11 (Program Director) reviewed the records for the staff listed above, and confirmed that was documentation available for viewing during the inspection that any of the staff were Program Leader qualified.
Plan of Correction: The facility responded: All staff will not work alone with the children unless they have completed the required training to meet Program Leader qualifications.
Standard 8VAC20-780-530-A
Based on a review of eleven staff records and interviews, it was determined that the facility did not ensure that there shall be at least one staff in each classroom or area where children are present that has a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Evidence:
1. Neither of the staff working with the grouping of nine and ten year old children had a current
certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of
the children in care.
2. Neither of the staff working with the grouping of ten to twelve year old children (tweens) had
a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate
to the age of the children in care.
3. Staff #11 (Program Director) confirmed that staff in each of these groups did not have a
current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate
to the age of the children in care.
Evidence:
1. Neither of the staff working with the grouping of nine and ten year old children had a current
certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of
the children in care.
2. Neither of the staff working with the grouping of ten to twelve year old children (tweens) had
a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate
to the age of the children in care.
3. Staff #11 (Program Director) confirmed that staff in each of these groups did not have a
current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate
to the age of the children in care.
Plan of Correction: The facility responded: We will ensure that at least one staff in each grouping of children has a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Standard 8VAC20-780-60-A
Based on a review of ten children's records and interview, it was determined that the facility did not ensure that they maintain and keep at the center a complete record for each child enrolled that contains all required information.
Evidence
1. The record for child #3 did not contain documentation that the proof of identity was verified.
2. The record for child #5 did not contain a complete address for the emergency contacts.
3. Staff #11 (Program Director) confirmed that the records for child #3 and child #5 did not
contain all of the required information.
Evidence
1. The record for child #3 did not contain documentation that the proof of identity was verified.
2. The record for child #5 did not contain a complete address for the emergency contacts.
3. Staff #11 (Program Director) confirmed that the records for child #3 and child #5 did not
contain all of the required information.
Plan of Correction: The facility responded: The parents of each child will be asked to provide the
missing information
missing information