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Deborah Mays

Inspection · 2025-02-24

Date
2025-02-24
Complaint Related
No
Licensing Inspector
Sarah Zirzow
(703) 479-4675
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

8VAC20-800 Administration
8VAC20-800 Personnel
8VAC20-800 Household Members
8VAC20-800 Physical Health of Caregivers and Household members
8VAC20-800 Caregiver Training
8VAC20-800 Physical Equipment and Environment
8VAC20-800 Care of Children
8VAC20-800 Preventing the Spread of Disease
8VAC20-800 Medication Administration
8VAC20-800 Emergencies
8VAC20-800 Nutrition
8VAC20-800 Transportation
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
54.1 Provider must be MAT certified to administer prescription medication.
63.2 Child abuse and neglect

During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. 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 renewal inspection was initiated and completed on February 24, 2025, as a part of the licensure period. The on-site inspection began at 9:45 a.m. and ended at 11:00 a.m. The inspector reviewed compliance in the areas listed above. There were 2 children present and 1 caregiver; the point total was 4. The inspector reviewed 5 children?s records and 3 caregiver/household member(s) records on-site. This inspection included document review, tour of the home, interviews, and observations. Information gathered during the inspection determined non-compliance with applicable standards or law, 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 (5) business days from today, which will be the close of business on March 3, 2025. A POC submitted after this date will not appear on the public website.

Violations

14
Standard 22.1-289.036-B-4
The provider is required to obtain background checks from any state in which a household member has resided in the preceding five years.

The provider did not request a search of the criminal history, child abuse and neglect registry, and sex offender from one state for Household Member #2.
Plan of Correction: Will do required background checks on provider's 99-1/2 mother in law who moved in with provider due to medical reasons.
Standard 22.1-289.057-A
The program is required to submit to VDH and implement a plan to test potable water for lead.

The program did not have evidence of a testing plan submitted to VDH and the program did not have evidence of the implementation of the required testing plan.
Plan of Correction: The provider will comply with additional documentation as required. The provider has obtained testing kits and will retest all water sources.
Standard 8VAC20-800-100-A
Repeat Violation
The provider shall obtain documentation of a physical examination prior to a child's attendance or within 30 days after the first day of attendance.

There were no physical exam records available for Child #1, who had been in care for over 1 year and 4 months. There were no physical exam records available for Child #3, who had been in care for over 5 months.
Plan of Correction: VA Physical exam forms for child #1 & #3 have been misplaced by provider. Parents have been advised and will provide updated ones or copies of those on file at those children enrolled in preschool or elementary school.
Standard 8VAC20-800-170-A
Repeat Violation
The provider shall obtain from each adult household member prior to coming into contact with children a current Report of Tuberculosis Screening form published by the Virginia Department of Health or a form consistent with it documenting the absence of tuberculosis in a communicable form.

There was no documentation of a tuberculosis screening for Household Member #2.
Plan of Correction: Documentation of TB test for Household Member #2 will be on file ASAP but no later than 3/15/2025.
Standard 8VAC20-800-180-A
A tuberculosis (TB) screening is required every two years from the last screening.

The last documented tuberculosis screening for Household Member #1 was overdue by 9 months.
Plan of Correction: An updated documented screening will be obtained for household member #1 ASAP.
Standard 8VAC20-800-210-A
Caregivers shall obtain a minimum of 16 clock hours of training annually.

Caregiver #1 obtained 2 hours of training in 2024.
Plan of Correction: Provider will take additional trainings, in addition to personal research and reading that she does often, that offer certificates for proof of training.
Standard 8VAC20-800-50-A
Providers must keep a written record of children in attendance each day.

The provider did not take written attendance on February 17-21, 2025.
Plan of Correction: Provider will track attendance on daily schedule. Missed doing week of 2/17-21 due to provider being sick.
Standard 8VAC20-800-60-B
Repeat Violation
The provider is required to maintain a record for each enrolled child with the required information.

-The record for Child #1, who was present during the inspection and had been in care for over 1 year and 4 months, was missing their first date of attendance.
-The record for Child #2, who was present during the inspection and had been in care for over 1 year and 10 months, was missing the name, address, and phone number for one emergency contact and written authorization if the child is taken off the premises of the family day home.
-The record for Child #3, who had been present the morning of the inspection and had been in care for over 5 months, was missing the name, address and phone number for one emergency contact.
-The record for Child #5, who had been present the morning of the inspection and had been in care for over 1 year and 6 months, was missing written authorization if the child is taken off the premises of the family day home.
Plan of Correction: Item 1: Child has siblings in care also, date will be determined.
Item 2: Child has sibling in care and has had older siblings in care previously. Will have parents fill out 2nd emergency contact. Will also have parents sign separate permission slip for child to be taken off premises of family day home in addition to the clause in provider's contract that grants such permission.
Item 3: Has sibling in care: will have parents fill out 2nd emergency contact info. A copy of the VA State School Medical form on file at child's preschool has been requested.
Item 4: Provider has requested a copy of VA State Medical Exam on file at child's preschool.
Item 5: Will have parent sign separate permission slip to be off premises in addition to the clause in the provider's contract that grants such permission.
Standard 8VAC20-800-780-B
Annually, the provider shall review with the parent the emergency contact information required in each child?s record to ensure the information is correct and shall obtain the parents signed acknowledgment of the review.

Records for Child #2 and #4 did not have a parent?s signature for an annual review of the emergency contact information. Child #2 had been in care for over 1 year and 10 months and Child #4 had been in care for 1 year and 11 months.
Plan of Correction: All files will be reviewed with parents.
Standard 8VAC20-800-80-C
Repeat Violation
The provider shall document the method of verification of the child's age and identity in the child's record.

There was no documentation of the method of verification of the child's age and identity for Child #1, who had been in care for over 1 year and 4 months, or Child #2, who had been in care for over 1 year and 10 months.
Plan of Correction: Provider will again obtain and then complete document information as required.
Standard 8VAC20-800-830-A
Repeat Violation
The provider shall practice the emergency evacuation procedures monthly.

The last record of an emergency evacuation drill was 8/21/24.
Plan of Correction: Drill are practiced as required- provider will keep more accurate records.
Standard 8VAC20-800-90-A
Repeat Violation
Before attendance, documentation of immunizations is to be obtained for each child.

There was no documentation of immunizations for Child #1, who was in care during the inspection and had been in care for over 1 year and 4 months. There was no documentation of immunizations for Child #4, who was present the morning of the inspection and had been in care for over 5 months.
Plan of Correction: Immunization records for all children will be reviewed with parents and updated as needed.
Standard 8VAC20-800-90-C
Documentation of additional immunizations is required once every six months for children under the age of two years.

Child #2, 2 years old, last documented immunization was over 12 months ago and is overdue by 6 months.
-Child #4, 3 and a half years old, last documented immunization was over 3 years ago and is overdue by 2 years and 6 months.
Plan of Correction: Provider is obtaining all updated VA State School Health forms for all children enrolled in preschool and elementary school. Those not currently attending school she will obtain updated records from parents.
Standard 8VAC20-800-980-A
General written permission shall be obtained from the parent of each child for the provider to take the child off the premises of the family day home.

Child #1, who had been in care for over 1 year and 4 months, and Child #5, who had been in care for over 1 year and 6 months, did not have written permission from the parents to be taken off the premises of the family day home, in which they do so daily.
Plan of Correction: This permission is included in provider's contract that parents sign at time of enrollment on page 2; point 7 Under title of Responsibilities of parents/guardians.
View original record on Virginia Department of Social Services