Inspection · 2024-05-07
Date
2024-05-07
Complaint Related
No
Licensing Inspector
Angela Dudek
(804) 629-8167
(804) 629-8167
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
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
32.1 Report by person other than physician
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted on 05/07/2024 from 9:00am to 11:10am with the Assistant Director. There were 10 children ages 3 years old to age 5 years old supervised by 3 staff and 3 volunteers. The physical plant, programming, attendance, menus, 3 staff records, 3 children?s records, 1 medication with corresponding authorization records, emergency drills, emergency supplies, and policies were reviewed. Due to the weather, the playground was not inspected. Children were observed participating in dramatic play, art and building activities. There was an adequate number of staff present with current certification in Medication Administration Training (MAT), CPR and First Aid, and Daily Health Observation (DHO) training. Areas of non-compliance are identified in the Violation Notice. Missing background checks must be sent no later than 10 days from the date of inspection.
Please complete the columns for "Plan of Correction" and "Date to be Corrected" for each violation cited on the Violation Notice, and then return a signed and dated copy of each page to me via email by 5pm on 5/15/24. Please email me at angela.dudek@doe.virginia.gov with any questions.
Violations
17Standard 22.1-289.011-F
Based on observation and staff interview, the center did not ensure they post the findings of the most recent licensing inspection of the facility.
Evidence: The most recent licensing inspection of the facility was not posted.
Evidence: The most recent licensing inspection of the facility was not posted.
Plan of Correction: Never received the document from the last inspector even after repeated attempts to contact them. Apparently when an inspector is out on vacation no one responds to their emails for them. Then we received notice that we had a new inspector. The new one is posted.
Standard 22.1-289.035-B-2
Based on review of 3 Staff records, 3 Volunteer records and staff interview, the provider did not obtain documentation of the results of a national fingerprint background check prior to volunteering.
Evidence: The record for for Volunteer #1 (start date 10/17/23), Volunteer #2 (start date 10/17/23) and Volunteer #3 (start date 10/17/23) did not contain documentation that a fingerprint background check was completed.
Evidence: The record for for Volunteer #1 (start date 10/17/23), Volunteer #2 (start date 10/17/23) and Volunteer #3 (start date 10/17/23) did not contain documentation that a fingerprint background check was completed.
Plan of Correction: These are high school students who volunteer as part of a class they attend. They come in only once a week and are transported by the schools and a teacher who has had al required background check stay with them at all times. They are no longer volunteering.
Standard 8VAC20-770-60-B
Based on review of 3 Staff records, 3 volunteer records and staff interview, the center did not obtain documentation of a completed sworn disclosure statement for each volunteer prior to volunteering.
Evidence: The record for Volunteer #1 (start date 10/17/23), Volunteer #2 (start date 10/17/23) and Volunteer #3 (start date 10/17/23) did not contain documentation of a completed sworn disclosure statement.
Evidence: The record for Volunteer #1 (start date 10/17/23), Volunteer #2 (start date 10/17/23) and Volunteer #3 (start date 10/17/23) did not contain documentation of a completed sworn disclosure statement.
Plan of Correction: These are high school students who volunteer as part of a class they attend. They come in only once a week and are transported by the schools and a teacher who had had all required background check stay with them at all times. They are no longer volunteering.
Standard 8VAC20-770-60-C-2
Based on review of 3 Staff records, 3 volunteer records and staff interview, the center did not obtain documentation that a central registry search was completed by the end of the 30th day of volunteering.
Evidence: The record for Volunteer #1 (start date 10/17/23), Volunteer #2 (start date 10/17/23) and Volunteer #3 (start date 10/17/23) did not contain documentation that a central registry search was completed.
Evidence: The record for Volunteer #1 (start date 10/17/23), Volunteer #2 (start date 10/17/23) and Volunteer #3 (start date 10/17/23) did not contain documentation that a central registry search was completed.
Plan of Correction: These are high school students who volunteer as part of a class they attend. They come in only once a week and are transported by the schools and a teacher who has had al required background check stay with them at all times. They are no longer volunteering.
Standard 8VAC20-780-140-A
(Repeat Violation) Based on review of 3 child records, the center did not obtain documentation of a physical examination under the direction of a physician for a child prior to the first day of attendance or within 30 days after the first day of attendance.
Evidence: The record for child #3 (Start date 9/5/23) did not contain documentation of a physical.
Evidence: The record for child #3 (Start date 9/5/23) did not contain documentation of a physical.
Plan of Correction: The corrected physical was printed from ProCare and online health and contact system.
Standard 8VAC20-780-160-A
Based on review of 3 staff records, 3 volunteer records, and interview with staff, the center did not obtain documentation of a negative tuberculosis (TB) test or screening for staff and volunteers at the time of employment and prior to contact with children and within 30 days prior to employment.
Evidence:
1)The file for Staff #2 (date of hire 9/3/03) did not contain documentation of a negative tuberculosis (TB) test or screening.
2)The file for Volunteer #1 (start date 10/17/23), Volunteer #2 (start date 10/17/23) and Volunteer #3 (start date 10/17/23) did not contain documentation of a negative TB test or screening.
Evidence:
1)The file for Staff #2 (date of hire 9/3/03) did not contain documentation of a negative tuberculosis (TB) test or screening.
2)The file for Volunteer #1 (start date 10/17/23), Volunteer #2 (start date 10/17/23) and Volunteer #3 (start date 10/17/23) did not contain documentation of a negative TB test or screening.
Plan of Correction: These are high school students who volunteer as part of a class they attend. They come in only once a week and are transported by the schools and a teacher who has had al required background check stay with them at all times. They are no longer volunteering.
Standard 8VAC20-780-240-I
(Repeat Violation) Based on review of 3 staff records and interview with staff, the center did not ensure that orientation documentation was kept for each staff member.
Evidence:
The file for Staff #2 (date of hire 9/3/03) did not contain documentation of an orientation.
Evidence:
The file for Staff #2 (date of hire 9/3/03) did not contain documentation of an orientation.
Plan of Correction: We are in the process of getting this information from our HR which is off site. We are a community center and do not have an HR department on site.
Standard 8VAC20-780-260-B
Based on documentation and staff interview, the center did not ensure that they receive annual approval from the health department or approvals of a plan of correction, for meeting requirements for water supply, sewage disposal system and food service if applicable.
Evidence: The center did not have an inspection completed from the health department within the last year. The last inspection on file was dated 2/28/23.
Evidence: The center did not have an inspection completed from the health department within the last year. The last inspection on file was dated 2/28/23.
Plan of Correction: Reaching out again for inspection, as the county has not responded to our repeated efforts to schedule an inspection.
Standard 8VAC20-780-280-B
(Repeat Violation) Based on observation, the center did not ensure that hazardous substances were kept in a locked place using a safe locking method that prevents access by children.
Evidence:
1)During inspection in the classroom restroom that children use, a bottle of toilet cleaner was observed on top of the paper towel dispenser and in an unlocked area.
2)During inspection in the classroom, a bottle of toilet cleaner was stored in an unlocked bottom cabinet, 3 disinfectants were stored on an open shelf where children?s backpacks are kept, and a bottle of floor cleaner was stored on an open shelf where children?s backpacks are kept.
3)During inspection in the classroom, a storage closet was observed unlocked and open and there was a bin on an open shelf that contained 2 disinfectants, a bottle of lice treatment, a bottle of floor cleaner, and a bottle of rubbing alcohol.
Evidence:
1)During inspection in the classroom restroom that children use, a bottle of toilet cleaner was observed on top of the paper towel dispenser and in an unlocked area.
2)During inspection in the classroom, a bottle of toilet cleaner was stored in an unlocked bottom cabinet, 3 disinfectants were stored on an open shelf where children?s backpacks are kept, and a bottle of floor cleaner was stored on an open shelf where children?s backpacks are kept.
3)During inspection in the classroom, a storage closet was observed unlocked and open and there was a bin on an open shelf that contained 2 disinfectants, a bottle of lice treatment, a bottle of floor cleaner, and a bottle of rubbing alcohol.
Plan of Correction: 1. Cleaner was removed, and placed in the closet.
2. Cleaner was removed and placed in the closet.
Remind staff the importance of keeping the closet locked.
2. Cleaner was removed and placed in the closet.
Remind staff the importance of keeping the closet locked.
Standard 8VAC20-780-290-A-3
Based on observation, the center did not ensure that electrical outlets have protective covers.
Evidence: In the restroom located within the classroom, there was an outlet that did not have a protective cover.
Evidence: In the restroom located within the classroom, there was an outlet that did not have a protective cover.
Plan of Correction: We had one cover in the restroom, which now contains a covering.
Standard 8VAC20-780-40-M
Based on review of documentation and interview with the staff, the center did not maintain a current and dated written list of children?s allergies, sensitivities, and dietary restrictions that was accessible to all staff in each group or area where children are present.
Evidence:
1)During inspection of the classroom, there was no written, dated list of children?s allergies, sensitivities, and dietary restrictions in the classroom and accessible for the staff. The list was kept in an office in another area of the facility.
2)Child #2 had a physician diagnosed allergy indicated in their file that was not present on the list of children?s allergies, sensitivities, and dietary restrictions.
3)Child #3 had a physician diagnosed allergy indicated in their file that was different than the allergy specified on the list of children?s allergies, sensitivities, and dietary restrictions.
Evidence:
1)During inspection of the classroom, there was no written, dated list of children?s allergies, sensitivities, and dietary restrictions in the classroom and accessible for the staff. The list was kept in an office in another area of the facility.
2)Child #2 had a physician diagnosed allergy indicated in their file that was not present on the list of children?s allergies, sensitivities, and dietary restrictions.
3)Child #3 had a physician diagnosed allergy indicated in their file that was different than the allergy specified on the list of children?s allergies, sensitivities, and dietary restrictions.
Plan of Correction: 1. Typed up and print an allergy list, as it was accidently taken down during cleaning.
2. It has not been added to the list.
3. Mom mentioned the child had been tested for allergies, however, she was having the child retested. When we received the actual physical the child was allergic. List has been updated.
2. It has not been added to the list.
3. Mom mentioned the child had been tested for allergies, however, she was having the child retested. When we received the actual physical the child was allergic. List has been updated.
Standard 8VAC20-780-510-L
Based on observation, the center did not ensure that medication be kept in a locked place using a safe locking method that prevents access by children.
Evidence: In the unlocked classroom storage room, there was an unlocked first aid kit box stored on a shelf that contained several packets of triple antibiotic ointment and a packet of acetaminophen.
Evidence: In the unlocked classroom storage room, there was an unlocked first aid kit box stored on a shelf that contained several packets of triple antibiotic ointment and a packet of acetaminophen.
Plan of Correction: Staff has been reminded to keep the door closed and locked.
Standard 8VAC20-780-550-E
Based on review of documentation, the center did not ensure they implement a practice shelter in place drill twice per year.
Evidence: There was no documentation on file for Shelter in place drills.
Evidence: There was no documentation on file for Shelter in place drills.
Plan of Correction: The shelter in place was completed, it just was not listed on separate forms.
Standard 8VAC20-780-560-G
Based on observation, the center did not ensure that food brought from home was clearly dated and labeled in a way that identifies the owner.
Evidence:
1)During inspection in the classroom, a child?s backpack contained a lunch box full of food from home that did not contain a date or name of the owner.
2)During inspection in the classroom, a second child?s backpack contained a lunch box full of food from home that did not contain a date.
Evidence:
1)During inspection in the classroom, a child?s backpack contained a lunch box full of food from home that did not contain a date or name of the owner.
2)During inspection in the classroom, a second child?s backpack contained a lunch box full of food from home that did not contain a date.
Plan of Correction: The food was in each child's cubby that is clearly labeled with that child's name. Some parents do put their child's name on their lunch box.
As it clearly marked by their cubby, there is no need for a remedy as well as the teachers assist students to assure the correct child has their correct food, and the students know which food is theirs. As for the date, what they bring each day is for that day, and they take it home at the end of each day.
As it clearly marked by their cubby, there is no need for a remedy as well as the teachers assist students to assure the correct child has their correct food, and the students know which food is theirs. As for the date, what they bring each day is for that day, and they take it home at the end of each day.
Standard 8VAC20-780-60-A
(Repeat Violation) Based on review of 3 child records, the Center did not ensure they obtain all of the required documentation for child records.
Evidence:
1) The file for Child #1 was missing the name, address, and phone number of one of the emergency contacts and was missing the address of the second emergency contact.
2)The files for Child #1, Child #2 and Child #3 did not contain questions answered by the children?s parents related to chronic physical problems and special accommodations needed, emergency medical care authorization, and previous or current child care centers attended.
3)The files for Child #1 and Child #2 did not contain a parent?s work place and phone number.
Evidence:
1) The file for Child #1 was missing the name, address, and phone number of one of the emergency contacts and was missing the address of the second emergency contact.
2)The files for Child #1, Child #2 and Child #3 did not contain questions answered by the children?s parents related to chronic physical problems and special accommodations needed, emergency medical care authorization, and previous or current child care centers attended.
3)The files for Child #1 and Child #2 did not contain a parent?s work place and phone number.
Plan of Correction: We have updated our forms to include that information.
1,2,3-the information is on ProCare, our online health and contact registration system. Which we have access to in the classroom when we are in session. We have printed the information needed and are in the process of creating physical forms for parents to fill out for the future.
1,2,3-the information is on ProCare, our online health and contact registration system. Which we have access to in the classroom when we are in session. We have printed the information needed and are in the process of creating physical forms for parents to fill out for the future.
Standard 8VAC20-780-60-A-8
(Repeat Violation) Based on review of 3 child records, the provider did not ensure they had a written care plan for each child with a diagnosed food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
Evidence: The records for Child #2 and Child #3 did not contain allergy care plans for their physician diagnosed food allergies.
Evidence: The records for Child #2 and Child #3 did not contain allergy care plans for their physician diagnosed food allergies.
Plan of Correction: We have requested the parents obtain a Allergy Plan. The doctors refuse to complete an Allergy Plan, as what they have provided Clearly states what to look for and what steps are to be taken in the event the child ingest the food in which they are allergic to.
Standard 8VAC20-780-70
(Repeat Violation) Based on review of 3 staff records, 3 volunteer records and interview with staff, the center did not obtain all of the required documentation for staff and volunteer records.
Evidence:
1)The center did not have documentation for Staff #1, Staff #2, and Staff #3 that two or more references as to character and reputation as well as competency were checked before employment.
2) The center did not have documentation for Staff #1, Staff #2 and Staff #3 of emergency contact addresses as required.
3)The center did not have any documentation on file for Volunteer #1 (start date 10/17/23), Volunteer #2(start date 10/17/23) and Volunteer #3(start date 10/17/23) including two or more references, name, address and phone number of emergency contacts, age verification and home address.
Evidence:
1)The center did not have documentation for Staff #1, Staff #2, and Staff #3 that two or more references as to character and reputation as well as competency were checked before employment.
2) The center did not have documentation for Staff #1, Staff #2 and Staff #3 of emergency contact addresses as required.
3)The center did not have any documentation on file for Volunteer #1 (start date 10/17/23), Volunteer #2(start date 10/17/23) and Volunteer #3(start date 10/17/23) including two or more references, name, address and phone number of emergency contacts, age verification and home address.
Plan of Correction: 1. We have received these from HR
These are high school students who volunteer as part of a class they attend. They come in only once a week and are transported by the schools and a teacher who has had al required background check stay with them at all times. They are no longer volunteering.
These are high school students who volunteer as part of a class they attend. They come in only once a week and are transported by the schools and a teacher who has had al required background check stay with them at all times. They are no longer volunteering.