Inspection · 2024-04-22
Date
2024-04-22
Complaint Related
No
Licensing Inspector
Dominick Fields
(540) 359-5244
(540) 359-5244
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced renewal inspection was initiated on 4/22/24 and concluded on 4/22/24.
5 staff records and 5 child records were reviewed. One additional staff record was reviewed only for specific items. 2 additional child records were reviewed only for specific items.
Violations were reviewed with administration at the exit interview.
Children were observed resting quietly during the inspection. Emergency escape drills, emergency supplies, first aid supplies, menu, cot spacing and top & Bottom covers were all in
compliance.
If you have questions regarding this inspection, you may contact me at (703) 479-4678 or at Sarah.Marbert@does.virginia.gov.
LI was present today from 12:35PM - 3:10PM.
Please submit your plan of correction within 5 business days in order for it to be included on the website.
An amended report was sent to the facility, due to Board Officer background checks being incomplete,
Violations
18Standard 22.1-289.036-A
Based on a review of records, Board Officer records did not contain documentation of repeated background searches in the allowable five year time frame.
Evidence:
Board Officer A - fingerprint results are dated 8/18/18 (expired 8/17/23).
Officer B - Sworn Disclosure Statement (SDS) was dated 5/11/18 (expired 5/10/23)
Evidence:
Board Officer A - fingerprint results are dated 8/18/18 (expired 8/17/23).
Officer B - Sworn Disclosure Statement (SDS) was dated 5/11/18 (expired 5/10/23)
Plan of Correction: Sworn Disclosure Statement was completed and is now on file.
Fingerprinting was done and we are waiting on the results.
Fingerprinting was done and we are waiting on the results.
Standard 8VAC20-770-40-D-1-a
Based on a review of records, board officers did not have a completed Sworn Disclosure Statement (SDS) or Central Registry searches when becoming board officers.
Evidence:
Three officers, had no SDS available at the time of the review of records.
(Officers C,D,E)
Three officers had no Central Registry Search results available for review.
(Officers C,D,E)
Evidence:
Three officers, had no SDS available at the time of the review of records.
(Officers C,D,E)
Three officers had no Central Registry Search results available for review.
(Officers C,D,E)
Plan of Correction: Central registry searches have been submitted for all officers.
Sworn Disclosure statements have been completed and are now on file.
Sworn Disclosure statements have been completed and are now on file.
Standard 8VAC20-780-180-C
Based on a review of records, staff transporting children had not disclosed any traffic violations that occurred prior to or during employment or assigned as a driver.
Evidence:
Staff C's record did not have a driver's statement available disclosing any traffic violations.
Evidence:
Staff C's record did not have a driver's statement available disclosing any traffic violations.
Plan of Correction: Driving statement was drawn up and completed by staff bus drivers.
Standard 8VAC20-780-245-A
Based on a review of records, staff records did not contain documentation of completing annually a minimum of 16 hours of training appropriate to the age of children in care.
Evidence;
4 of 5 staff records reviewed did not contain 16 hours of annual training.
1. Staff A had no hours documented.
2. Staff B had 8 of 16 hours documented.
3. Staff E had no hours documented.
4. Staff F had no hours documented.
Evidence;
4 of 5 staff records reviewed did not contain 16 hours of annual training.
1. Staff A had no hours documented.
2. Staff B had 8 of 16 hours documented.
3. Staff E had no hours documented.
4. Staff F had no hours documented.
Plan of Correction: Staff are now applying for classroom hours.
Standard 8VAC20-780-245-J
Repeat Violation
Based on a review of staff records, children with emergency medications were not always in the care of a staff person current in medication administration training.
Evidence:
There were 2 medications in the School Age group of children, being transported to the facility.
The staff person transporting the children did not have a current certification in Medication Administration training (MAT). Certification expired 4/12/24.
Based on a review of staff records, children with emergency medications were not always in the care of a staff person current in medication administration training.
Evidence:
There were 2 medications in the School Age group of children, being transported to the facility.
The staff person transporting the children did not have a current certification in Medication Administration training (MAT). Certification expired 4/12/24.
Plan of Correction: MAT training completed for 3 staff.
Standard 8VAC20-780-340-F
Based on observation, children under 10 years of age were not within actual sight and sound supervision.
Evidence:
One occupied crib was placed around a corner from other cribs and a cot in the Toddler room.
The staff member was seated in a rocking chair at the opposite end of the carpeted area, where they could not see the occupied crib.
Evidence:
One occupied crib was placed around a corner from other cribs and a cot in the Toddler room.
The staff member was seated in a rocking chair at the opposite end of the carpeted area, where they could not see the occupied crib.
Plan of Correction: Spoke to staff. Cots and cribs to be arranged for better observation.
Standard 8VAC20-780-350-B-1
Based on observation, a 1 staff to 4 children ratio was not maintained in the infant room.
Evidence:
At LI arrival in the infant room(approximately 12:45PM) there were 6 infants with one staff supervising the room.
Evidence:
At LI arrival in the infant room(approximately 12:45PM) there were 6 infants with one staff supervising the room.
Plan of Correction: Spoke to staff. We will ensure ratios be maintained.
Standard 8VAC20-780-40-J
Based on a review of the injury prevention plan, the plan had not been updated annually.
Evidence:
The plan available for review was dated 1/2023.
Evidence:
The plan available for review was dated 1/2023.
Plan of Correction: Plan to be renewed
Standard 8VAC20-780-40-M
Based on observation, the center did not maintain a current written list of all children's allergies in each room where children were present.
Evidence:
No allergy list was available in 6 of 6 classrooms.
(Infants, Toddlers, Penguins, Pandas, Tigers, Zebras)
Evidence:
No allergy list was available in 6 of 6 classrooms.
(Infants, Toddlers, Penguins, Pandas, Tigers, Zebras)
Plan of Correction: Reprinted for all classrooms
Standard 8VAC20-780-440-B
Repeat Violation
Based on observation, cribs in use were not labeled to identify use by a specific child.
Evidence:
1. In the Toddler room, 3 cribs were in use by children that had a different child's name on the crib..
2. In the Infant room, 2 cribs in use had a different child's name on the crib.
Based on observation, cribs in use were not labeled to identify use by a specific child.
Evidence:
1. In the Toddler room, 3 cribs were in use by children that had a different child's name on the crib..
2. In the Infant room, 2 cribs in use had a different child's name on the crib.
Plan of Correction: Spoke to staff. Must be more aware of where children are being placed.
Standard 8VAC20-780-440-N
Based on observation, an object was hung over an infant crib being used by a child over 5 months of age.
Evidence:
Child #8 (7 months old) had a mobile hung over their crib.
Evidence:
Child #8 (7 months old) had a mobile hung over their crib.
Plan of Correction: Mobile removed from crib. Spoke to staff
Standard 8VAC20-780-510-E
Repeat Violation
Based on observation, one long term medication authorization signed by the physician was not acceptable.
Evidence:
Child #5's medication authorization, was an authorization for Fairfax County Schools to administer the medication, not the center.
Based on observation, one long term medication authorization signed by the physician was not acceptable.
Evidence:
Child #5's medication authorization, was an authorization for Fairfax County Schools to administer the medication, not the center.
Plan of Correction: Gave mom new paperwork to be signed by the doctor.
Standard 8VAC20-780-510-L
Repeat Violation
Based on observation, one medication was not stored locked using a safe locking method.
Evidence:
One medication was stored in the Penguins classroom in a "ziplock baggie".
(Child 6)
Based on observation, one medication was not stored locked using a safe locking method.
Evidence:
One medication was stored in the Penguins classroom in a "ziplock baggie".
(Child 6)
Plan of Correction: New Safety Saks were ordered for medications.
Standard 8VAC20-780-560-G
Based on observation, food brought from home was not labeled and dated in a way that identified the owner.
Evidence:
Fruit cups in the Toddler room refrigerator were not labeled or dated.
Evidence:
Fruit cups in the Toddler room refrigerator were not labeled or dated.
Plan of Correction: Spoke to Staff about labeling food from home.
Standard 8VAC20-780-570-A
Based on observation, an infant was in an infant seat without the safety strap being fastened.
Evidence:
An infant laying in an infant seat was observed with not safety strap fastened.
Evidence:
An infant laying in an infant seat was observed with not safety strap fastened.
Plan of Correction: Spoke to staff about safety of child. (Straps to be fastened)
Standard 8VAC20-780-60-A
Repeat Violation
Systemic Deficiency
Based on a review of records, child records did not contain all required information.
Evidence:
5 records reviewed. Missing information includes:
1. No second emergency contacts listed. (Child 3)
2. Parent work information (Children #1,2,3,5)
3. Second parent name, address, phone number. (Child 3)
4. Signature of person viewing the Proof of Birth Documentation. (Child 4)
Systemic Deficiency
Based on a review of records, child records did not contain all required information.
Evidence:
5 records reviewed. Missing information includes:
1. No second emergency contacts listed. (Child 3)
2. Parent work information (Children #1,2,3,5)
3. Second parent name, address, phone number. (Child 3)
4. Signature of person viewing the Proof of Birth Documentation. (Child 4)
Plan of Correction: 1.
2. Child #1 done
Child #3 done
Child #5 done
Child #2 done
4. Signed Proof of birth document
2. Child #1 done
Child #3 done
Child #5 done
Child #2 done
4. Signed Proof of birth document
Standard 8VAC20-780-60-A-8
Repeat Violation
Systemic Deficiency
Based on a review of documentation, a written allergy action plan was not updated annually for a child with a diagnosed food allergy.
Evidence:
Child #6 has an allergy action plan on site. The plan was not updated annually.
The form is dated 10/7/22.
Systemic Deficiency
Based on a review of documentation, a written allergy action plan was not updated annually for a child with a diagnosed food allergy.
Evidence:
Child #6 has an allergy action plan on site. The plan was not updated annually.
The form is dated 10/7/22.
Plan of Correction: Spoke to parent. They will return new forms from the doctor.
Standard 8VAC20-780-80-A
Based on a review of documentation, the center did not maintain a written record of daily attendance that documented the arrival and departure of children as it occurred.
Evidence:
2 classrooms had no attendance sheet completed for 4/22/24. (Pandas, Penguins)
Evidence:
2 classrooms had no attendance sheet completed for 4/22/24. (Pandas, Penguins)
Plan of Correction: Spoke to staff of importance of daily markings.