Inspection · 2022-10-04
Date
2022-10-04
Complaint Related
No
Licensing Inspector
Pamela Sneed
(804) 629-2691
(804) 629-2691
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
Conducted an unannounced renewal inspection at 11:37am. Observed both the morning and afternoon programs. Ratios and supervision were in compliance. Children were engaged in a wide variety of outdoor education activities and the staff were actively engaged with the children. The program is predominantly an outdoor education program, weather permitting. Suitable indoor space is available and used when there is inclement weather. Areas of non-compliance were found with standards and laws reviewed. Questions about this inspection may be directed to pamela.sneed@doe.virginia.gov
12/6/22 ? The program director submitted outstanding documents.
12/16/22 ? A revised inspection report was issued to reflect documents submitted on 12/6/22. Background check non-compliance has been determined to be a systemic issue. The license cannot be renewed until board member background checks are completed.
Violations
9Standard 22.1-289-036-B-4
Updated 12/6/22:
Based on records reviewed, it was determined that 2 of 4 board member records did not include required out-of-state background checks.
Evidence:
1. Board member #1 ? No out-of-state CRC, CPS, and sex offender registry check (SOR) have not been completed.
2. Board member #2 - No out-of-state CRC, CPS, and SOR have been completed.
Based on records reviewed, it was determined that 2 of 4 board member records did not include required out-of-state background checks.
Evidence:
1. Board member #1 ? No out-of-state CRC, CPS, and sex offender registry check (SOR) have not been completed.
2. Board member #2 - No out-of-state CRC, CPS, and SOR have been completed.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-A
Updated 12/6/22:
Based on records reviewed, it was determined that 2 of 5 staff records did not include required background checks completed within the last 5 years.
Evidence:
1. Staff #3 ? A current CRC + CPS were not completed. Date of hire was 2001.
2. Staff #8 ? A current CRC + CPS were not completed. Date of volunteering was 2021, and employment was 2022.
Based on records reviewed, it was determined that 2 of 5 staff records did not include required background checks completed within the last 5 years.
Evidence:
1. Staff #3 ? A current CRC + CPS were not completed. Date of hire was 2001.
2. Staff #8 ? A current CRC + CPS were not completed. Date of volunteering was 2021, and employment was 2022.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-B-2
Updated 12/6/22:
Based on records reviewed, it was determined 1 of 5 staff records included background checks completed more than 12 months prior to a break in volunteering/employment with the school. Evidence: Staff #9 ? The staff person left volunteer service with the school in 2020, was hired as staff in 2022, and the background checks on-file were dated 2019. This includes a sworn disclosure statement (SDS), criminal record check (CRC), and CPS.
Based on records reviewed, it was determined 1 of 5 staff records included background checks completed more than 12 months prior to a break in volunteering/employment with the school. Evidence: Staff #9 ? The staff person left volunteer service with the school in 2020, was hired as staff in 2022, and the background checks on-file were dated 2019. This includes a sworn disclosure statement (SDS), criminal record check (CRC), and CPS.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-40-D-1-a
Based on interview conducted and renewal application submitted, it was determined that the background checks for board members/business entity were not submitted. Evidence: The background checks for 4 of 4 current board members and the designated contact person, as listed on the Business Entity page of the renewal application were not submitted to the inspector for review by the established deadline of 9/30/22. To-date, the background checks have not been made available to the inspector.
Updated 12/6/22:
Based on records reviewed, it was determined that 1 of 4 board members does not have a required central registry check (CPS) completed. Evidence: Board member #2 ? No CPS check submitted.
Updated 12/6/22:
Based on records reviewed, it was determined that 1 of 4 board members does not have a required central registry check (CPS) completed. Evidence: Board member #2 ? No CPS check submitted.
Plan of Correction: The program director submitted most of the requested board member background checks on 12/6/22.
Standard 8VAC20-770-60-C-2
Updated 12/6/22:
Based on records reviewed, it was determined that 2 of 5 staff records do not include a required CPS check within the first 30-days of employment.
Evidence:
1. Staff #7 ? No CPS check was completed. Date of hire was September 2021.
2. Staff #8 ? No CPS check was completed. Date of hire was September 2022.
Based on records reviewed, it was determined that 2 of 5 staff records do not include a required CPS check within the first 30-days of employment.
Evidence:
1. Staff #7 ? No CPS check was completed. Date of hire was September 2021.
2. Staff #8 ? No CPS check was completed. Date of hire was September 2022.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-160-C
Updated 12/6/22:
Based on records reviewed, it was determined that 2 of 6 staff records did not include documentation of a current TB test/screening completed in the previous 2 years.
Evidence:
1. Staff #1 ? No TB test completed.
2. Staff #3 ? The TB document submitted does not include the results of the test.
Based on records reviewed, it was determined that 2 of 6 staff records did not include documentation of a current TB test/screening completed in the previous 2 years.
Evidence:
1. Staff #1 ? No TB test completed.
2. Staff #3 ? The TB document submitted does not include the results of the test.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-260-A
Based on interview conducted, it was determined that an annual fire inspection has not been completed. Evidence: The previous fire inspection permit expired 5/4/22.
Plan of Correction: Completed and document submitted to inspector on 12/6/22.
Standard 8VAC20-780-270-A
Based on observations made, it was determined that a piece of outdoor play equipment was in an unsafe condition. Evidence: A large metal climbing pipe had sharp rusted edges that could potentially cut a child?s skin.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-70
Based on records requested, it was determined that information in staff records that is required to be maintained on-site was not done so; and that staff records were not made available to the inspector for review, as agreed upon.
Evidence:
1. The name, address, age verification, job title, date of employment/volunteering, and the name, address and phone number for an emergency contact was not available on-site for each employee during the inspection.
2. The program director reported that this information was at the home of Staff #4, who was working on staff records.
3. 6 of 6 staff records requested by the inspector were not submitted by the established deadline of 9/30/22. To-date, the records have not been made available to the inspector.
Updated 12/6/22:
1. Staff #8 ? There was no documentation of 1 of 2 required reference checks.
2. Staff #9 - There was no documentation of 1 of 2 required reference checks.
Evidence:
1. The name, address, age verification, job title, date of employment/volunteering, and the name, address and phone number for an emergency contact was not available on-site for each employee during the inspection.
2. The program director reported that this information was at the home of Staff #4, who was working on staff records.
3. 6 of 6 staff records requested by the inspector were not submitted by the established deadline of 9/30/22. To-date, the records have not been made available to the inspector.
Updated 12/6/22:
1. Staff #8 ? There was no documentation of 1 of 2 required reference checks.
2. Staff #9 - There was no documentation of 1 of 2 required reference checks.
Plan of Correction: The program director submitted most of the requested staff records on 12/6/22.