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Trinity Lutheran Church

Inspection · 2025-09-18

Date
2025-09-18
Complaint Related
No
Licensing Inspector
Jennifer Moore
(540) 430-0384
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

22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
32.1 Report by person other than physician
54.1 Must be MAT Certified.
63.2 Child abuse and neglect
8VAC20-770 Background Checks

During the inspection, the inspector reviewed the areas listed above. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.

Inspector Notes

An unannounced, on-site code compliance inspection was conducted on 9/18/2025. The on-site inspection began at 12:00 pm and ended at 4:10 pm. The inspector reviewed compliance in the areas listed above. There were 52 children present with 10 staff. The inspector reviewed 5
children?s records and 5 staff records on site. This inspection included document review, a tour of the facility, interviews, and observations.

Information gathered during the inspection determined non-compliance(s) with applicable code sections, and violations are documented on the violation notice issued to the program.

Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the violation will be or has been corrected. Submit your POC within five business days from today, which will be the close of business on 9/29/2025. A POC submitted after this date will not appear on the public website.

Violations

5
Standard 22.1-289.031-A-4
Prior to providing supervision to children and annually thereafter, each person in a
supervisory position must be certified by a practicing physician or physician assistant
to be free from any disability that would prevent them from caring for children under their supervision.

Staff #2, employed for over one month, and Staff #5, employed for over two months, did not have staff health reports.
Plan of Correction: All staff will be required to have health forms (updated) on file and renew yearly.
Standard 22.1-289.035-B-1
The center is required to obtain a completed sworn statement prior to the employee's first day of employment.

The sworn statement for Staff #2, who has been employed for one month, was not completed. The sworn statement for Staff #5, who has been employed for two months, was not completed.
Plan of Correction: Staff #2 Sworn Statement is in place. All staff will be required to have a sworn statement on file before beginning work.
Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employee's first day of employment.

Staff #2, who had been employed for one month, did not have a completed national criminal background check. Staff #5 had a completed national criminal background check that was completed three days after the start of employment.
Plan of Correction: Staff #2 OBI completed. All staff will be required to complete OBI eligibility before employment.
Standard 22.1-289.035-B-3
The center must request a search of the central registry prior to the employee's first day of employment.

Staff #2, who had been employed for one month, had a search of the central registry that was conducted over two weeks after the start of employment. Staff #5, who had been employed for two months, had a search of the central registry that was conducted over two weeks after the start of employment. The results for both checks had not been received and administration acknowledged that the staff had worked alone with children.
Plan of Correction: Staff #2 and #5 central registry search completed. All staff will have CRS completed and on file before beginning employment.
Standard 22.1-289.049-A
RECDC programs shall require that the person enrolling a child in the program present proof of the child's identity and age.

The records of Child#1 and Child #3, enrolled for two years, did not have documentation of viewing proof of the child's age and identity. The record of Child #4, enrolled or one year, did not have documentation of viewing proof. The record of Child #5, enrolled for one month, did not contain viewing proof. The RECDC has written procedures that include requesting and retaining a copy of the proof of age and identity, and a secondary area in the record to retain identity verification information that were both missing for Child #1, #3, #4 and #5.
Plan of Correction: Children must be identified when enrolling in the program and a copy of proof kept in the student file. Identification verification info will also be recorded on student contracts.
View original record on Virginia Department of Social Services