Inspection · 2023-10-10
Date
2023-10-10
Complaint Related
No
Licensing Inspector
Lynette A Storr
(703) 309-9153
(703) 309-9153
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)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced Renewal Inspection took place on October 10, 2023 between the hours of approximately 9:25 a.m. and 12:50 p.m. There were 5 classrooms observed with a total of 54 children with 12 staff within the supervision guidelines. The children were observed eating breakfast outside, playing with blocks and puzzles, returning from the playground and other organized activities. A complete inspection of the physical plant, children and staff records, fire drill log, medication and emergency procedures were observed during this inspection. 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, please e-mail me at tameika.king@doe.virginia.gov. Thank you for your cooperation during the inspection.
Violations
14Standard 22.1-289.035-B-4
REPEAT VIOLATION
Based on record review and staff interview, the center failed to obtain a copy of the results of a criminal history record check prior to the first day of employment and results of a child abuse and neglect search by the end of the 30th day of employment for a staff member, from any state in which the individual has resided in the preceding five years.
Evidence:
1. Staff #4 confirmed that Staff #2 (start date: 09/04/2023) resided out of state in the preceding five years.
2. Staff #2?s record does not contain results of an out-of-state criminal history record check or results of an out-of-state child abuse and neglect search.
Based on record review and staff interview, the center failed to obtain a copy of the results of a criminal history record check prior to the first day of employment and results of a child abuse and neglect search by the end of the 30th day of employment for a staff member, from any state in which the individual has resided in the preceding five years.
Evidence:
1. Staff #4 confirmed that Staff #2 (start date: 09/04/2023) resided out of state in the preceding five years.
2. Staff #2?s record does not contain results of an out-of-state criminal history record check or results of an out-of-state child abuse and neglect search.
Plan of Correction: The criminal history search for staff 2 will be
requested again and once received, the results
will be placed in the file and forwarded to the
licensing inspector. Going forward, center
management will ensure staff criminal history
searches are followed up on 3 weeks, if not
received within 30 days of being requested the
administrators will call/email and document all
communication in the staff file. Before staff first
day search and printout all out of state child
abuse and neglect results.
requested again and once received, the results
will be placed in the file and forwarded to the
licensing inspector. Going forward, center
management will ensure staff criminal history
searches are followed up on 3 weeks, if not
received within 30 days of being requested the
administrators will call/email and document all
communication in the staff file. Before staff first
day search and printout all out of state child
abuse and neglect results.
Standard 22.1-289.036-B-2
Based on record review, the center failed to obtain fingerprinting results for a staff member every five years.
Evidence: Staff #5?s most recent fingerprinting results was dated 04/23/2018.
Evidence: Staff #5?s most recent fingerprinting results was dated 04/23/2018.
Plan of Correction: An updated central registry search has been
completed for staff 5. Once received, the results
will be placed in staff 5's file and forwarded to the
licensing inspector. Going forward, center
administrators will use a shared spreadsheet and
add calendar reminders to a ensure repeat central
registry search requests are completed every 5
years.
completed for staff 5. Once received, the results
will be placed in staff 5's file and forwarded to the
licensing inspector. Going forward, center
administrators will use a shared spreadsheet and
add calendar reminders to a ensure repeat central
registry search requests are completed every 5
years.
Standard 8VAC20-770-60-B
Based on record review, an employee of the center was employed before the center had the person?s completed sworn statement.
Evidence: Staff #2 (start date 09/04/2023) did not have a sworn disclosure statement on file.
Evidence: Staff #2 (start date 09/04/2023) did not have a sworn disclosure statement on file.
Plan of Correction: The Sworn statement was signed and placed in
staff 2's file. The Director will make sure every
form is signed and placed in the file on or before
the first day of employment.
staff 2's file. The Director will make sure every
form is signed and placed in the file on or before
the first day of employment.
Standard 8VAC20-780-160-A
REPEAT VIOLATION
Based on record review, not all staff members submitted documentation of a negative tuberculosis (TB) screening at the time of employment.
Evidence: Staff #3?s (start date: 08/09/2023) documentation of a TB screening was dated 08/16/2023.
Based on record review, not all staff members submitted documentation of a negative tuberculosis (TB) screening at the time of employment.
Evidence: Staff #3?s (start date: 08/09/2023) documentation of a TB screening was dated 08/16/2023.
Plan of Correction: Going forward, the center will ensure new staff
obtain TB screenings by their first day of
employment and before coming in contact with
children.
obtain TB screenings by their first day of
employment and before coming in contact with
children.
Standard 8VAC20-780-240-C
REPEAT VIOLATION
Based on record review, the center failed to include all topics for staff orientation training.
Evidence: The center?s orientation training did not include prevention of shaken baby syndrome and abusive head trauma or prevention of and response to emergencies due to food and other allergic reactions.
Based on record review, the center failed to include all topics for staff orientation training.
Evidence: The center?s orientation training did not include prevention of shaken baby syndrome and abusive head trauma or prevention of and response to emergencies due to food and other allergic reactions.
Plan of Correction: The director has updated the orientation training to
include shaken baby syndrome ,abusive head
trauma and prevention of and response to
emergencies due to food and other allergic
reactions. All staff will be trained and given the
updated document to sign.
include shaken baby syndrome ,abusive head
trauma and prevention of and response to
emergencies due to food and other allergic
reactions. All staff will be trained and given the
updated document to sign.
Standard 8VAC20-780-260-B
Based on record review and staff interview, the center failed to obtain annual approval from the health department for meeting requirements for water supply and sewage disposal system.
Evidence: Staff #4 confirmed that the center had not obtained a sanitation inspection.
Evidence: Staff #4 confirmed that the center had not obtained a sanitation inspection.
Plan of Correction: The director was unaware of the inspection. The
inspection has been requested and is scheduled
for 10/20/2023. upon completion a copy will be
sent to the licensing inspector.
inspection has been requested and is scheduled
for 10/20/2023. upon completion a copy will be
sent to the licensing inspector.
Standard 8VAC20-780-290-A-3
Based on observation, electrical outlets did not have protective covers.
Evidence:
1. There was on outlet uncovered under the fan in the Green Dragonflies classroom.
2. There was one outlet under the whiteboard and two outlets under the teacher board uncovered in the Blue Dragonflies classroom.
Evidence:
1. There was on outlet uncovered under the fan in the Green Dragonflies classroom.
2. There was one outlet under the whiteboard and two outlets under the teacher board uncovered in the Blue Dragonflies classroom.
Plan of Correction: The outlet covers were replaces and an
an opening and closing list to all
classrooms to be checked by opening
and closing administrators and staff
daily.
an opening and closing list to all
classrooms to be checked by opening
and closing administrators and staff
daily.
Standard 8VAC20-780-350-F
Based on staff interview, the center failed to develop a written policy and procedure that describes how the center will ensure that each group of children receives care by consistent staff.
Evidence: Staff #4 confirmed that the center had not developed a written policy and procedure on consistency of staff.
Evidence: Staff #4 confirmed that the center had not developed a written policy and procedure on consistency of staff.
Plan of Correction: The center will develop a written policy and
procedure that describes how each group of
children are being cared for by consistent staff
members.
procedure that describes how each group of
children are being cared for by consistent staff
members.
Standard 8VAC20-780-40-I
Based on staff interview, the center failed to develop written procedures for injury prevention.
Evidence: Staff #4 confirmed that the center did not have written procedures for injury prevention.
Evidence: Staff #4 confirmed that the center did not have written procedures for injury prevention.
Plan of Correction: The injury prevention plan will be completed by
11/30/2023. We will do our annual plan every
August to ensure that we keep up with annual
requirements.
11/30/2023. We will do our annual plan every
August to ensure that we keep up with annual
requirements.
Standard 8VAC20-780-40-K
Based on staff interview, the center failed to develop written procedures for prevention of shaken baby syndrome or abusive head trauma.
Evidence: Staff #4 confirmed that the center did not have written procedures for prevention of shaken baby syndrome or abusive head trauma.
Evidence: Staff #4 confirmed that the center did not have written procedures for prevention of shaken baby syndrome or abusive head trauma.
Plan of Correction: The center will develop written procedures for
shaken baby syndrome or abusive head trauma.
shaken baby syndrome or abusive head trauma.
Standard 8VAC20-780-500-B
Based on observation, disposable diapers were not disposed in a storage system that is either foot-operated or used in such a way that neither the staff member?s hand nor the soiled diaper touches the exterior surface during disposal.
Evidence: The bathroom in the Tadpoles classroom contained a battery-operated trash can that is designed to open by waving your hand over it. During the inspection, the trash can was not opening automatically, causing staff to open it manually, by hand.
Evidence: The bathroom in the Tadpoles classroom contained a battery-operated trash can that is designed to open by waving your hand over it. During the inspection, the trash can was not opening automatically, causing staff to open it manually, by hand.
Plan of Correction: The Director purchased a new foot pedal
operated trash can and added an opening and
closing list to all classrooms to be checked by
opening and closing administrators.
operated trash can and added an opening and
closing list to all classrooms to be checked by
opening and closing administrators.
Standard 8VAC20-780-510-I
Based on record review, the center failed to ensure that requirements were met when administering prescription medication.
Evidence:
1. A medication administration log indicated that Staff #4 administered a prescription medication to Child #6 on 10/02/2023.
2. There was no written authorization from a parent or guardian for the medication on file.
3. The medication did not have a prescription label.
Evidence:
1. A medication administration log indicated that Staff #4 administered a prescription medication to Child #6 on 10/02/2023.
2. There was no written authorization from a parent or guardian for the medication on file.
3. The medication did not have a prescription label.
Plan of Correction: The parent of child 6 was contacted and written
authorization to administer medication was
obtained and placed in child 6's file. Going
forward, center administrators will ensure that
medication is not administered to children in care
without written authorization from the parent.
The form was given to the parent to complete. The
director informed the staff that written consent
must be provided on the form and cannot be given
via Brightwheel. From now on, the administration
team will check all medication books upon the
arrival of new medication at the center and on a
monthly basis.
authorization to administer medication was
obtained and placed in child 6's file. Going
forward, center administrators will ensure that
medication is not administered to children in care
without written authorization from the parent.
The form was given to the parent to complete. The
director informed the staff that written consent
must be provided on the form and cannot be given
via Brightwheel. From now on, the administration
team will check all medication books upon the
arrival of new medication at the center and on a
monthly basis.
Standard 8VAC20-780-60-A
REPEAT VIOLATION
Based on record review, the center failed to obtain all information for 1 out of 5 children?s records.
Evidence: Child #2?s (start date: 07/25/2022) record did not contain an address for emergency contact #1 and #2.
Based on record review, the center failed to obtain all information for 1 out of 5 children?s records.
Evidence: Child #2?s (start date: 07/25/2022) record did not contain an address for emergency contact #1 and #2.
Plan of Correction: The administrators have scheduled a document
update day with the parents. Moving forward all
files will be reviewed annually in August.
update day with the parents. Moving forward all
files will be reviewed annually in August.
Standard 8VAC20-780-70
REPEAT VIOLATION/ SYSTEMIC DEFIENCY
Based on record review, the center failed to obtain all information for 5 out of 6 staff records.
Evidence:
1. Staff #1?s (start date: 05/12/2023) record did not contain documentation that two or more references were checked before employment.
2. Staff #2?s (start date: 09/04/2023) did not contain documentation that two or more references were checked before employment.
3. Staff #3?s (start date: 08/09/2023) record did not contain documentation that two or more references were checked before employment.
4. Staff #4?s (start date: 03/11/2021) record did not contain documentation that two or more references were checked before employment.
5. Staff #6?s (start date: 10/02/2023) did not documentation that two or more references were checked before employment.
6. Staff #3 and Staff #6?s records did not contain a name, address and telephone number of a person to be notified in an emergency.
Based on record review, the center failed to obtain all information for 5 out of 6 staff records.
Evidence:
1. Staff #1?s (start date: 05/12/2023) record did not contain documentation that two or more references were checked before employment.
2. Staff #2?s (start date: 09/04/2023) did not contain documentation that two or more references were checked before employment.
3. Staff #3?s (start date: 08/09/2023) record did not contain documentation that two or more references were checked before employment.
4. Staff #4?s (start date: 03/11/2021) record did not contain documentation that two or more references were checked before employment.
5. Staff #6?s (start date: 10/02/2023) did not documentation that two or more references were checked before employment.
6. Staff #3 and Staff #6?s records did not contain a name, address and telephone number of a person to be notified in an emergency.
Plan of Correction: The hiring checklist has been updated. All new
hires must have two reference checks prior to
their start date. Reference checks will also be
performed immediately for all current staff.
hires must have two reference checks prior to
their start date. Reference checks will also be
performed immediately for all current staff.