Inspection · 2023-05-01
Date
2023-05-01
Complaint Related
No
Licensing Inspector
Stephanie Reed
(540) 272-6558
(540) 272-6558
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
A renewal inspection was conducted on May 1, 2023 from 8:00 A.M.-1:15 P.M. There were 47 children present, ranging in ages from 5 months to five years of age, with nine 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 six child records and ten 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 540-430-9257.
Violations
11Standard 22.1-289.035-B-4
Based on a review of staff files, the center failed to ensure that all out-of-state background checks were completed within the required timeframe.
Evidence:
1. Staff #6 disclosed on the sworn disclosure statement dated 04/25/2023 that they had previously lived in two other states within the past five years.
2. Staff #6 date of hire was 04/24/2023 there was not a sex offender name search completed and on file for the two states. There was not an out-of-state criminal history check completed and on file for one state. Both the out of state sex offender name search, and the criminal history are required prior to the first date of employment.
3. Staff #6 was observed working with a group of children on May 1, 2023.
4. Staff #3 verified that the out-of-state background checks had not been completed.
Evidence:
1. Staff #6 disclosed on the sworn disclosure statement dated 04/25/2023 that they had previously lived in two other states within the past five years.
2. Staff #6 date of hire was 04/24/2023 there was not a sex offender name search completed and on file for the two states. There was not an out-of-state criminal history check completed and on file for one state. Both the out of state sex offender name search, and the criminal history are required prior to the first date of employment.
3. Staff #6 was observed working with a group of children on May 1, 2023.
4. Staff #3 verified that the out-of-state background checks had not been completed.
Plan of Correction: Out of state sex offender name searches have been completed and the out of state criminal history search has been sent.
Standard 8VAC20-770-40-D-1-a
Based on a review of board member background checks, the center failed to ensure that search of central registry was on file within 30 days of the board member taking office.
Evidence:
1. Agent #1's file did not contain a completed central registry finding. Date of service began 10/07/2020.
2. Staff #3 verified that the record did not contain a completed central registry finding.
Evidence:
1. Agent #1's file did not contain a completed central registry finding. Date of service began 10/07/2020.
2. Staff #3 verified that the record did not contain a completed central registry finding.
Plan of Correction: Administration will check to see if the completed central registry was ever sent back, and if it can't be located a new one will be completed.
Standard 8VAC20-770-60-B
Based on review of staff records, the center failed to ensure that a sworn disclosure statement was signed by the first date of employment.
Evidence:
1. Staff #4's date of hire was 04/24/2023. The sworn disclosure statement was dated 04/27/2023.
2. Staff #5's date of hire was 04/24/2023. The sworn disclosure statement was dated 04/25/2023.
2. Staff #3 confirmed the dates of hire and the dates on the sworn disclosure statements.
Evidence:
1. Staff #4's date of hire was 04/24/2023. The sworn disclosure statement was dated 04/27/2023.
2. Staff #5's date of hire was 04/24/2023. The sworn disclosure statement was dated 04/25/2023.
2. Staff #3 confirmed the dates of hire and the dates on the sworn disclosure statements.
Plan of Correction: Our new hire checklist will be updated to reflect a required timeline for background checks and references to be completed.
Standard 8VAC20-780-270-A
REPEAT VIOLATION
Based on observation, the center failed to ensure that all areas inside and outside shall be maintained in safe and operable condition.
Evidence:
In the Pre-K 1 Classroom there is peeling paint on the molding located near the block area.
Based on observation, the center failed to ensure that all areas inside and outside shall be maintained in safe and operable condition.
Evidence:
In the Pre-K 1 Classroom there is peeling paint on the molding located near the block area.
Plan of Correction: Peeling paint along the molding of the PS1 classroom will be correctly removed and repainted.
Standard 8VAC20-780-40-E
Based on review of emergency plan, the center failed to comply with their own policies and procedures.
Evidence:
1. In the emergency preparedness plan it states the following, "once a year, the director will meet with local authorities to review the above security checks."
2. The plan was dated that it was last updated in January 2022.
3. Staff #3 verified that the emergency preparedness plan had not been updated since January 2022.
Evidence:
1. In the emergency preparedness plan it states the following, "once a year, the director will meet with local authorities to review the above security checks."
2. The plan was dated that it was last updated in January 2022.
3. Staff #3 verified that the emergency preparedness plan had not been updated since January 2022.
Plan of Correction: The center's Emergency plan has been updated
Standard 8VAC20-780-500-A
REPEAT VIOLATION
Based on observation, the center failed to ensure that staff washed their hands with soap and running water before and after a diaper change.
Evidence:
1. In the Toddler Classroom, Staff #1, was observed preparing for and completing a diaper change. Staff #1 did not wash her hands before putting the gloves on and starting the diaper change.
2. In the Toddler Classroom, Staff #1, did not change the gloves in between diaper changes.
Based on observation, the center failed to ensure that staff washed their hands with soap and running water before and after a diaper change.
Evidence:
1. In the Toddler Classroom, Staff #1, was observed preparing for and completing a diaper change. Staff #1 did not wash her hands before putting the gloves on and starting the diaper change.
2. In the Toddler Classroom, Staff #1, did not change the gloves in between diaper changes.
Plan of Correction: Diapering procedures have been reviewed with the Staff observed, and diapering procedures, including appropriate handwashing, and will be reviewed with all Staff during our mandatory Staff meeting scheduled for May 10th. Admin will randomly check during diapering times and review again as needed over the next 2 weeks, then periodically thereafter.
Standard 8VAC20-780-500-B
Based on observation and interview, the center failed to ensure that a nonabsorbent surface for diapering or changing was used ,and that diapering surfaces were cleaned with soap and at least room temperature water and sanitized after each use.
Evidence:
1. In the Infant Classroom the diaper changing mat was torn and ripped on two of the corners exposing the foam.
2. In the Toddler Classroom, Staff #1, did not clean the diapering surface with water and soap before sanitizing the diapering surface.
3. Staff #1 confirmed that she did not spray the diapering surface with water and soap to first clean the surface.
Evidence:
1. In the Infant Classroom the diaper changing mat was torn and ripped on two of the corners exposing the foam.
2. In the Toddler Classroom, Staff #1, did not clean the diapering surface with water and soap before sanitizing the diapering surface.
3. Staff #1 confirmed that she did not spray the diapering surface with water and soap to first clean the surface.
Plan of Correction: Diapering procedures have been reviewed with the Staff observed, and diapering procedures, including appropriate handwashing, and will be reviewed with all Staff during our mandatory Staff meeting scheduled for May 10th. Admin will randomly check during diapering times and review again as needed over the next 2 weeks, then periodically thereafter.
Standard 8VAC20-780-520-A
Based on observation, the center failed to ensure that all over-the-counter skin products shall not be kept beyond the expiration date.
Evidence:
1. In the Waddler Classroom there was a tube of Aquaphor that expired in March 2023.
2. Staff #2 verified that the Aquaphor had expired in March 2023.
Evidence:
1. In the Waddler Classroom there was a tube of Aquaphor that expired in March 2023.
2. Staff #2 verified that the Aquaphor had expired in March 2023.
Plan of Correction: Expired diaper ointment has been sent home and all diaper cream in the classroom has been checked for expiration. Before accepting new diaper ointment, all containers will be checked for expiration and the date will be noted on the permission form.
Standard 8VAC20-780-530-A-1
Based on observation and interview, the center failed to ensure that at least one staff in each classroom or area where children are present shall be certified in cardiopulmonary resuscitation (CPR).
Evidence:
1. On 05/01/2023 between 8:00 A.M.-9:00 A.M. there was not a staff member certified in CPR in the Waddler Classroom.
2. Staff #3 verified that the staff member is not currently certified in CPR.
Evidence:
1. On 05/01/2023 between 8:00 A.M.-9:00 A.M. there was not a staff member certified in CPR in the Waddler Classroom.
2. Staff #3 verified that the staff member is not currently certified in CPR.
Plan of Correction: We are in contact with a CPR/First Aid instructor to schedule certification as soon as possible. Once a date has been set, licensing inspector will be notified. Until we get current certifications schedule will be reworked to ensure all classrooms have someone with a current certification.
Standard 8VAC20-780-530-A-2
Based on observation and interview, the center failed to ensure that at least one staff in each classroom or area where children are present shall be certified in first aid.
Evidence:
1. On 05/01/2023 between 8:00 A.M.-9:00 A.M. there was not a staff member certified in First Aid in the Waddler Classroom.
2. Staff #3 verified that the staff member is not currently certified in First Aid.
Evidence:
1. On 05/01/2023 between 8:00 A.M.-9:00 A.M. there was not a staff member certified in First Aid in the Waddler Classroom.
2. Staff #3 verified that the staff member is not currently certified in First Aid.
Plan of Correction: We are in contact with a CPR/First Aid instructor to schedule certification as soon as possible. Once a date has been set, licensing inspector will be notified. Until we get current certifications schedule will be reworked to ensure all classrooms have someone with a current certification.
Standard 8VAC20-780-70
Based on a review of staff records, the center failed to ensure that two or reference checks as to character and reputation as well as competency were checked before employment.
Evidence:
1.. Staff #1's first date of employment was 02/13/2023. There were no completed reference checks in the file.
2. Staff #2's first date of employment was 04/24/2023. There were no completed reference checks in the file.
3. Staff #4's first date of employment was 04/24/2023. There were no completed reference checks in the file.
4. Staff #5's first date of employment was 04/03/2023. There were no completed reference checks in the file.
5. Staff #1's first date of employment was 02/13/2023. There were no completed reference checks in the file.
6. Staff #6's first date of employment was 04/24/2023. There were no completed reference checks in the file.
7. Staff #7's first date of employment was 04/24/2023. There were no completed reference checks in the file.
8. Staff #3 verified that there were no reference check in all the files.
Evidence:
1.. Staff #1's first date of employment was 02/13/2023. There were no completed reference checks in the file.
2. Staff #2's first date of employment was 04/24/2023. There were no completed reference checks in the file.
3. Staff #4's first date of employment was 04/24/2023. There were no completed reference checks in the file.
4. Staff #5's first date of employment was 04/03/2023. There were no completed reference checks in the file.
5. Staff #1's first date of employment was 02/13/2023. There were no completed reference checks in the file.
6. Staff #6's first date of employment was 04/24/2023. There were no completed reference checks in the file.
7. Staff #7's first date of employment was 04/24/2023. There were no completed reference checks in the file.
8. Staff #3 verified that there were no reference check in all the files.
Plan of Correction: Reference checks are in the process of being conducted for each new staff. Moving forward, our new hire checklist will be updated to reflect a required timeline for background checks and references to be completed.