Inspection · 2023-01-19
Date
2023-01-19
Complaint Related
No
Licensing Inspector
Cassie Anderson-Leichty
(757) 409-4668
(757) 409-4668
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 Early Childhood Care and Education
63.2 Child Abuse & Neglect
Inspector Notes
A monitoring inspection was initiated on January 19, 2023 and concluded on January 19, 2023. There were 17 children present, ranging in ages from 3 years to age 5 years, with 2 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 5 child records and 5 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 about this inspection, please contact Christine Mahan, Licensing Inspector at (757) 404-0568 or Christine.mahan@doe.virginia.gov
Violations
11Standard 22.1-289.035-B-2
Based on review of 5 staff records and staff interviews, the licensee did not ensure, all staff obtained a Criminal Records Check (CRC) prior to the first day of employment.
Evidence: The record for Staff #3 (date of hire 10-31-2022) and Staff #4 (date of hire 9-19-2022) did not include a CRC. Staff #1 confirmed the missing information and that Staff #3 and Staff #4 were working on the day of the inspection
Evidence: The record for Staff #3 (date of hire 10-31-2022) and Staff #4 (date of hire 9-19-2022) did not include a CRC. Staff #1 confirmed the missing information and that Staff #3 and Staff #4 were working on the day of the inspection
Plan of Correction: Staff #4 and Staff #3 have completed the forms for CRC.
Standard 22.1-289.035-B-4
Based on review of 5 staff records and staff interviews, the licensee did not ensure, all staff had obtained an out of state criminal history name check (CRC) prior to the first day of employment and an out of state child abuse and neglect search (CPS) request by the 30th day of employment.
Evidence: The record for Staff #2 (date of hire 3-21-2022) did not include the CRC and a CPS for the state of Arizona where they had lived within the last 5 years. Staff #1 confirmed the missing information and that Staff #2 was working on the day of the inspection.
Evidence: The record for Staff #2 (date of hire 3-21-2022) did not include the CRC and a CPS for the state of Arizona where they had lived within the last 5 years. Staff #1 confirmed the missing information and that Staff #2 was working on the day of the inspection.
Plan of Correction: Staff #2 will complete forms to obtain CPS & CRC from Arizona.
Standard 8VAC20-770-60-C-2
Based on a review of 5 staff records and staff interviews, the licensee did not ensure each staff member had obtained by the end of the 30th day of hire the results of the Central Registry (CPS) finding for the state of Virginia.
Evidence: The record for Staff #1 (date of hire 9-12-22) and Staff #3 (date of hire 10-31-22 does not have documentation of a CPS check conducted. Staff #1 confirmed both Staff #1 and Staff #3 were working on the day of inspection.
Evidence: The record for Staff #1 (date of hire 9-12-22) and Staff #3 (date of hire 10-31-22 does not have documentation of a CPS check conducted. Staff #1 confirmed both Staff #1 and Staff #3 were working on the day of inspection.
Plan of Correction: Staff f#1 and Staff #3 will complete paper work for CPS asap.
Standard 8VAC20-780-130-A
Based on record review and staff interviews, the licensee did not ensure to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence: The record for Child #2, (first date of attendance 1-9-2023) first date of attendance was verified by Staff # 1 did not include documentation of required immunizations prior to attendance.
Evidence: The record for Child #2, (first date of attendance 1-9-2023) first date of attendance was verified by Staff # 1 did not include documentation of required immunizations prior to attendance.
Plan of Correction: Child #2 as of Jan 24, 2023 has immunizations within the chart.
Standard 8VAC20-780-240-A
Based on a review of 5 record and staff interviews, the licensee did not ensure each staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence: The records for Staff # 1 (hire date 9-12-2022), Staff #2 (date of hire 3-2-2022), Staff #3 (date of hire 10-31-22 and Staff #4 (date of hire 9-19-2022) did not include information indicating orientation had been completed. Staff #1 confirmed missing documentation.
Evidence: The records for Staff # 1 (hire date 9-12-2022), Staff #2 (date of hire 3-2-2022), Staff #3 (date of hire 10-31-22 and Staff #4 (date of hire 9-19-2022) did not include information indicating orientation had been completed. Staff #1 confirmed missing documentation.
Plan of Correction: Orientation will be conducted for all staffers #1 through #4
Standard 8VAC20-780-240-C
Based on a review of 5 staff records and staff interviews, the licensee did not ensure each staff member had completed orientation training in all required facility specific topics prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
Evidence: The records for Staff # 1 (hire date 9-12-2022), Staff #2 (date of hire 3-2-2022), Staff #3 (date of hire 10-31-22 and Staff #4 (date of hire 9-19-2022) did not include information indicating orientation related abusive head trauma, including procedures to cope with distraught children was obtained. Staff #1 confirmed missing documentation.
Evidence: The records for Staff # 1 (hire date 9-12-2022), Staff #2 (date of hire 3-2-2022), Staff #3 (date of hire 10-31-22 and Staff #4 (date of hire 9-19-2022) did not include information indicating orientation related abusive head trauma, including procedures to cope with distraught children was obtained. Staff #1 confirmed missing documentation.
Plan of Correction: Staff #1 will be making arrangements for Staffers 2-4 will receive mentioned training.
Standard 8VAC20-780-260-B
Based on documentation review and staff interviews, the licensee did not ensure to obtain an annual approval from the health department.
Evidence: The most recent copy of the health inspection available for review was date 4-26-2019.
Evidence: The most recent copy of the health inspection available for review was date 4-26-2019.
Plan of Correction: Staff #1 has contacted the Health Department to request an updated health inspection.
Standard 8VAC20-780-40-K
Based on review of center documentation and staff interviews, the licensee did not ensure the center shall develop written procedures for abusive head trauma.
Evidence: Staff #1 confirmed there was not a policy available for review related to head trauma.
Evidence: Staff #1 confirmed there was not a policy available for review related to head trauma.
Plan of Correction: Staff #1 will share information with board members regarding a policy for abusive head trauma.
Standard 8VAC20-780-550-G
Based on staff interviews and review of documentation, the licensee did not ensure to maintain documentation of monthly emergency evacuation drills.
Evidence: Staff #1 confirmed they did not have documentation of evacuation drills available for review for January 2022, July 2022 and August 2022 and lockdown drill conducted in 2022.
Evidence: Staff #1 confirmed they did not have documentation of evacuation drills available for review for January 2022, July 2022 and August 2022 and lockdown drill conducted in 2022.
Plan of Correction: The drill information will be located and available for review once found.
Standard 8VAC20-780-70
Based on a review of 5 staff records and staff interviews, the licensee did not ensure the staff records were kept for each staff person with all required information.
Evidence: The following information was not available during the record review and Staff #1 confirmed the missing information.
1)Staff #1, the designated Program Director does not have documentation to demonstrate they possesses the education, certification, and experience required by the job position.
2) There was not documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering for Staff #1, Staff #3 and Staff #4.
Evidence: The following information was not available during the record review and Staff #1 confirmed the missing information.
1)Staff #1, the designated Program Director does not have documentation to demonstrate they possesses the education, certification, and experience required by the job position.
2) There was not documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering for Staff #1, Staff #3 and Staff #4.
Plan of Correction: Staff #1 and #3 as of Jan 25, 2023 have at lest 2 refences within their chart. Staff #4 has a reference page in her chart with dates 9/13/2022 and staff #5 and Staff #2 will be requested to submit at least 2 references.
Standard 8VAC20-820-120-E-2
Based on observation and staff interviews, the licensee did not ensure the license and any other documents required by the Superintendent were posted in a conspicuous place on the licensed premises.
Evidence: The most recent inspection results dated January 28, 2022 were not posted in a conspicuous place. The inspection posted was dated April 4, 2021.
Evidence: The most recent inspection results dated January 28, 2022 were not posted in a conspicuous place. The inspection posted was dated April 4, 2021.
Plan of Correction: Place updated important documentation in the proper place for review.