Inspection · 2023-12-07
Date
2023-12-07
Complaint Related
No
Licensing Inspector
Beth Orebaugh
(540) 847-9173
(540) 847-9173
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
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced monitoring inspection was conducted on 12/07/2023 from 9:50 a.m. to 1:45 p.m. There were 100 children present, ranging in ages from three months to five years ols with 19 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 10 child records and 12 staff records were reviewed.
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.
If you have any questions or concerns, please contact the Licensing Inspector at (804) 629-3923.
Violations
15Standard 22.1-289.035-B-4
Based on review of records, the center failed to ensure that out of state sex offender registry check was completed by the first day of employment.
Evidence:
1. Staff #6?s start date was 11/08/2023. The out of state sex offender registry check on file was not dated. Staff #13 could not provide documentation that the out of state sex offender registry check was completed before Staff #6?s first day of employment.
Evidence:
1. Staff #6?s start date was 11/08/2023. The out of state sex offender registry check on file was not dated. Staff #13 could not provide documentation that the out of state sex offender registry check was completed before Staff #6?s first day of employment.
Plan of Correction: Reprinted registry with correct date of 11/7/23.
Standard 8VAC20-780-130-A
Based on review of records, the center failed to ensure that each report of immunization are signed by a physician, his designee, or an official of the local health department.
Evidence:
1. Child #6?s immunization dated 08/02/2022 were not signed by a physician.
2. Child #8?s immunization dated 06/06/2022 and 08/21/2023 were not signed by a physician.
Evidence:
1. Child #6?s immunization dated 08/02/2022 were not signed by a physician.
2. Child #8?s immunization dated 06/06/2022 and 08/21/2023 were not signed by a physician.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-130-E
Based on review of records, the center failed to obtain documentation of additional immunization once every six months for children under the age of two years.
Evidence:
1. The record of immunizations on file for Child #3 were dated 10/14/2022 at three months old. Staff #13 confirmed there was no other record of immunization on file for Child #3 and that the center had no obtained documentation of additional immunization every six months.
2. The record of immunizations on file for Child #8 were dated 06/06/2022 at six months old and 08/21/2023 at one year and seven months old. Staff #13 confirmed that there was no documentation of immunization at one year old and that center had no obtained documentation of additional immunization every six months.
Evidence:
1. The record of immunizations on file for Child #3 were dated 10/14/2022 at three months old. Staff #13 confirmed there was no other record of immunization on file for Child #3 and that the center had no obtained documentation of additional immunization every six months.
2. The record of immunizations on file for Child #8 were dated 06/06/2022 at six months old and 08/21/2023 at one year and seven months old. Staff #13 confirmed that there was no documentation of immunization at one year old and that center had no obtained documentation of additional immunization every six months.
Plan of Correction: immunization records have been obtained for both children.
Standard 8VAC20-780-140-A
Based on review of records, the center failed to obtain documentation of a physical examination for each child before the child?s attendance or within 30 days of the first day of attendance.
Evidence:
1. Child #5?s start date was 08/14/2023. There was no documentation of a physical examination on file. Staff #13 confirmed that there was no documentation of a physical examination on file.
Evidence:
1. Child #5?s start date was 08/14/2023. There was no documentation of a physical examination on file. Staff #13 confirmed that there was no documentation of a physical examination on file.
Plan of Correction: Correct physical records have been obtained.
Standard 8VAC20-780-160-C
Based on review of records, the center failed to ensure staff obtain and submitted the results of a follow-up tuberculosis (TB) screening every two years.
Evidence:
1. The TB screening on file for Staff #5 was dated 11/10/2021. Staff #13 confirmed there was not a follow up TB screening every two years.
Evidence:
1. The TB screening on file for Staff #5 was dated 11/10/2021. Staff #13 confirmed there was not a follow up TB screening every two years.
Plan of Correction: Still will obtain TB test as soon as possible.
Standard 8VAC20-780-240-A
Based on review of records, the center failed to ensure that each staff completed the Virginia Department of Education ? sponsored orientation course within 90 days of employment.
Evidence:
1. Staff #2?s start date was 05/04/2023. There was no evidence that Staff #2 had completed the Virginia Department of Education ? sponsored orientation course.
2. Staff #13 confirmed that Staff #2 had not completed the Virginia Department of Education ? sponsored orientation course within 90 days of employment.
Evidence:
1. Staff #2?s start date was 05/04/2023. There was no evidence that Staff #2 had completed the Virginia Department of Education ? sponsored orientation course.
2. Staff #13 confirmed that Staff #2 had not completed the Virginia Department of Education ? sponsored orientation course within 90 days of employment.
Plan of Correction: Staff member completed course but cannot print certificate; we are working to find out reason.
Standard 8VAC20-780-240-E
Based on review of record, the center failed to ensure that the required information in each child?s file is review by parents annually.
Evidence:
1. Child #4?s start date was 08/16/2021. There was no update on file.
2. Child #6?s start date was 08/22/2022. There was no update on file.
3. Child #10?s start date was 10/22/2021. There was not update on file.
3. Staff #13 confirmed that the information had not be review annually by parents.
Evidence:
1. Child #4?s start date was 08/16/2021. There was no update on file.
2. Child #6?s start date was 08/22/2022. There was no update on file.
3. Child #10?s start date was 10/22/2021. There was not update on file.
3. Staff #13 confirmed that the information had not be review annually by parents.
Plan of Correction: files have all been updated with correct enrollment dates.
Standard 8VAC20-780-330-B
Based on measurement, the center failed to ensure that where playground equipment is provided, resilient surfacing shall comply with minimum safety standards.
Evidence:
1. On the school age playground, the mulch measure four to four and half inches in varies spots.
2. On the preschool playground, the mulch measure four to four and half inches in varies spots.
Evidence:
1. On the school age playground, the mulch measure four to four and half inches in varies spots.
2. On the preschool playground, the mulch measure four to four and half inches in varies spots.
Plan of Correction: Rake mulch with ground thaws to acceptable levels.
Standard 8VAC20-780-340-D
Based on review of records and interview, the center failed to ensure that in each group of children at least one staff member who meets the program leader qualifications is regularly present.
Evidence:
1. In the Prek B classroom, Staff #13 confirmed that Staff #14 is the lead teacher that is regularly present. Staff #14 did not have evidence of lead qualification on file.
2. In the Infant room, there was four staff present. Staff #7 was the only lead qualified staff member present. Staff #13 confirmed that there was no other staff member in the classroom that had lead qualifications on file.
Evidence:
1. In the Prek B classroom, Staff #13 confirmed that Staff #14 is the lead teacher that is regularly present. Staff #14 did not have evidence of lead qualification on file.
2. In the Infant room, there was four staff present. Staff #7 was the only lead qualified staff member present. Staff #13 confirmed that there was no other staff member in the classroom that had lead qualifications on file.
Plan of Correction: Have staff immediately participate in the required trainings to meet the requirements within 30 days.
Standard 8VAC20-780-510-F
Based on review of records and interview, the center failed to ensure that the medication authorization is available to staff the entire time it is effective.
Evidence:
1. Documentation revealed that Benadryl is to be use for Child #1 in the event of an allergic reaction. There was no authorization form on file for Benadryl for Child #1.
2. Staff #13 confirmed that the medication was effective and there was no authorization form on file.
Evidence:
1. Documentation revealed that Benadryl is to be use for Child #1 in the event of an allergic reaction. There was no authorization form on file for Benadryl for Child #1.
2. Staff #13 confirmed that the medication was effective and there was no authorization form on file.
Plan of Correction: Parent is obtaining proper authorization from physician.
Standard 8VAC20-780-530-A-1
Based on review of record and interview, the center failed to ensure that at least one staff in each classroom or area where children are present has current cardiopulmonary resuscitation (CPR) certification.
Evidence:
1. Staff #8 was the only staff member in the Prep classroom. Staff #8?s CPR certification expired on 05/31/2023.
2. Staff #13 confirmed that Staff #8?s CPR certification was expired and there was no staff member with CPR certification in the Prep classroom.
Evidence:
1. Staff #8 was the only staff member in the Prep classroom. Staff #8?s CPR certification expired on 05/31/2023.
2. Staff #13 confirmed that Staff #8?s CPR certification was expired and there was no staff member with CPR certification in the Prep classroom.
Plan of Correction: Staff member will obtain proper certification as soon as class is available.
Standard 8VAC20-780-530-A-2
Based on review of record and interview, the center failed to ensure that at least one staff in each classroom or area where children are present has first aid certification.
Evidence:
1. Staff #8 was the only staff member in the Prep classroom. Staff #8?s first aid certification expired on 05/31/2023.
2. Staff #13 confirmed that Staff #8?s first aid certification was expired and there was no staff member with first aid certification in the Prep classroom.
Evidence:
1. Staff #8 was the only staff member in the Prep classroom. Staff #8?s first aid certification expired on 05/31/2023.
2. Staff #13 confirmed that Staff #8?s first aid certification was expired and there was no staff member with first aid certification in the Prep classroom.
Plan of Correction: Ensure all staff are first aid certified and have them take class as soon as possible.
Standard 8VAC20-780-560-G
Based on observation and interview, the cetner failed to ensure that when food is brought from home, it is clearly dated and labelled in a way that identifies the owner.
Evidence:
1. In the JK classroom, there were five cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
2. in the toddler classroom, there were nine cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
3. In the Montessori B classroom, there was one cup without a name and six cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
4. In the Prep classroom, there were four cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
5. In the Preschool A classroom, there were 2 cups without names and eight cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
6. In the Stepping Stones classroom, there were two cups without names or dates and two cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
7. In the Montessori A classroom, there were two cups without names and dates and four cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
Evidence:
1. In the JK classroom, there were five cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
2. in the toddler classroom, there were nine cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
3. In the Montessori B classroom, there was one cup without a name and six cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
4. In the Prep classroom, there were four cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
5. In the Preschool A classroom, there were 2 cups without names and eight cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
6. In the Stepping Stones classroom, there were two cups without names or dates and two cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
7. In the Montessori A classroom, there were two cups without names and dates and four cups without out dates. Staff #13 confirmed that the contains of the cups were brought from home.
Plan of Correction: Notify parents that water bottles much have names and dates.
Standard 8VAC20-780-60-A
Based on review of records, the center failed to ensure that each children?s record contained the required information.
Evidence:
1. Child #1?s file did not contain a work phone number for one parent.
2. Child #2?s file did not contain an address for one emergency contact and work phone numbers for both parents.
Evidence:
1. Child #1?s file did not contain a work phone number for one parent.
2. Child #2?s file did not contain an address for one emergency contact and work phone numbers for both parents.
Plan of Correction: file has been updated.
Standard 8VAC20-780-60-A-8
Based on review of records and interview, the center failed to ensure that each child with a diagnosed food allergy had a written care plan from a physician on file.
Evidence:
1. Documentation revealed that Child #1 had a diagnosed food allergy. There was no written care plan from a physician on file.
2. Staff #13 confirmed that there was no written care plan from a physician on file for Child #1.
Evidence:
1. Documentation revealed that Child #1 had a diagnosed food allergy. There was no written care plan from a physician on file.
2. Staff #13 confirmed that there was no written care plan from a physician on file for Child #1.
Plan of Correction: parent is obtaining proper documentation and care plan from physician.