Inspection · 2024-06-04
Date
2024-06-04
Complaint Related
No
Licensing Inspector
Kimberly Sampson
(757) 354-7307
(757) 354-7307
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 monitoring visit and facility tour was conducted on 6/4/24. At the time of inspectors' arrival there were 51 school aged children in care with 2 staff members. Children were observed interacting with staff, engaged in games and free play, and departure. A sample of 5 children's records and 4 staff records were reviewed. Injury reports were also reviewed. Staff reported medications are not being administered at this time. Areas of noncompliance are identified on the violation notice and were discussed with staff in an exit meeting at the conclusion of this inspection.
Violations
9Standard 22.1-289.035-B-4
Based on record review and interview it was determined the center did not request a search of the child abuse and neglect registry or equivalent registry from any state in which staff had resided in the preceding five years.
Evidence:
1. Staff #4 (hired 12/4/23) reported on their signed sworn statement that they had lived in North Carolina within the past five years. There was no documentation of a central registry search from North Carolina in the record for staff #4.
2. Staff confirmed this documentation was not available during this inspection.
Evidence:
1. Staff #4 (hired 12/4/23) reported on their signed sworn statement that they had lived in North Carolina within the past five years. There was no documentation of a central registry search from North Carolina in the record for staff #4.
2. Staff confirmed this documentation was not available during this inspection.
Plan of Correction: A central registry check will be completed for staff #4 for North Carolina.
Standard 8VAC20-770-60-C-2
Based on record review and interview it was determined the center did not ensure staff did not have a central registry finding within 30 days of employment.
Evidence:
1. There was no documentation of a central registry search in the record for staff #4 (hired 12/4/23).
2. There was no documentation of a central registry search in the record for staff #5 (hired 6/11/20).
3. Staff confirmed this documentation was not available during this inspection.
Evidence:
1. There was no documentation of a central registry search in the record for staff #4 (hired 12/4/23).
2. There was no documentation of a central registry search in the record for staff #5 (hired 6/11/20).
3. Staff confirmed this documentation was not available during this inspection.
Plan of Correction: Central registry checks will be completed for staff #4 and #5 for all necessary states.
Standard 8VAC20-780-160-A
Based on record review and interview it was determined the center did not have each staff member submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence:
1. The record for staff #5 did not contain documentation of a tuberculosis screening.
2. Staff confirmed this documentation was not available during this inspection.
Evidence:
1. The record for staff #5 did not contain documentation of a tuberculosis screening.
2. Staff confirmed this documentation was not available during this inspection.
Plan of Correction: Staff #5 now has a documented TB test in their staff file.
Standard 8VAC20-780-340-F
REPEAT VIOLATION
Based on observation it was determined the center did not ensure that all children under 10 years of age always shall be within actual sight and sound supervision of staff.
Evidence:
1. Upon inspector's arrival there were 21 children outside with staff #1. Staff#1 was seated in an entrance way with an obstructed view of at least 9 of the children outside.
2. When the inspector inquired staff did not know how many children were present that day, inside in the gym, or outside.
3. Children were observed during this inspection going back and forth between the outside playground areas and inside without staff knowing.
4. Staff confirmed the above during this inspection.
Based on observation it was determined the center did not ensure that all children under 10 years of age always shall be within actual sight and sound supervision of staff.
Evidence:
1. Upon inspector's arrival there were 21 children outside with staff #1. Staff#1 was seated in an entrance way with an obstructed view of at least 9 of the children outside.
2. When the inspector inquired staff did not know how many children were present that day, inside in the gym, or outside.
3. Children were observed during this inspection going back and forth between the outside playground areas and inside without staff knowing.
4. Staff confirmed the above during this inspection.
Plan of Correction: Staff have been debriefed on appropriate sight and sound supervision as well as
procedures for having children move from one area to another.
Staffing needs are being addressed through continuous employment of staff working for both the Summer programs and for school programs in the Fall. There will be another hiring event in July to build staff numbers for after school programs.
procedures for having children move from one area to another.
Staffing needs are being addressed through continuous employment of staff working for both the Summer programs and for school programs in the Fall. There will be another hiring event in July to build staff numbers for after school programs.
Standard 8VAC20-780-350-C
Based on observation and interview it was determined the center did not ensure that when children are in ongoing mixed age groups, the staff-to-children ratio and group size applicable to the youngest child in the group shall apply to the entire group.
Evidence:
1. There were 21 school aged children with the youngest being under 9 years old outside with staff #1 at the time of inspector's arrival.
2. There were approximately 30 school aged children with the youngest being under 9 years old in the gym with staff #2 at the time of the inspector's arrival.
3. Staff confirmed that they were not in ratio during this time.
Evidence:
1. There were 21 school aged children with the youngest being under 9 years old outside with staff #1 at the time of inspector's arrival.
2. There were approximately 30 school aged children with the youngest being under 9 years old in the gym with staff #2 at the time of the inspector's arrival.
3. Staff confirmed that they were not in ratio during this time.
Plan of Correction: Staffing needs are being addressed through hiring events and continuous employment of staff from the summer into the Fall school programs.
Standard 8VAC20-780-550-D
Based on record review and interview it was determined the center did not implement a practice evacuation drill monthly.
Evidence:
1. There was no evacuation drill documented since September 2023.
2. Staff confirmed there was no evacuation drill practiced since September 2023.
Evidence:
1. There was no evacuation drill documented since September 2023.
2. Staff confirmed there was no evacuation drill practiced since September 2023.
Plan of Correction: Administrative staff will conduct monthly drills and ensure appropriate documentation of drills are maintained.
Standard 8VAC20-780-60-A
Based on record review and interview it was determined the center did not ensure the record for each child enrolled contained all the required information.
Evidence:
1. The record for child #5 did not contain the two required emergency contacts.
2. Staff confirmed this information was not available during this inspection.
Evidence:
1. The record for child #5 did not contain the two required emergency contacts.
2. Staff confirmed this information was not available during this inspection.
Plan of Correction: Two emergency contacts for child #5 will be obtained and added to the child?s file.
Standard 8VAC20-780-70
Based on record review and interview it was determined the center did not ensure each staff record contained all the required information.
Evidence:
1. The staff record for staff #4, did not contain documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position of program leader.
2. The staff record for staff #5, did not contain documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position of program director.
3. Staff confirmed that this documentation was not available during this inspection.
Evidence:
1. The staff record for staff #4, did not contain documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position of program leader.
2. The staff record for staff #5, did not contain documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position of program director.
3. Staff confirmed that this documentation was not available during this inspection.
Plan of Correction: Administrative staff will audit the staff file and make necessary corrections to reflect the appropriate job position for staff #5.
Standard 8VAC20-780-90-A
Based on record review and interview it was determined the center did not ensure the required written agreement between the parent and the center was in each child's record by the first day of the child's attendance.
Evidence:
1. The record for child #3(enrolled 12/4/23) did not contain the required written agreements.
2. Staff confirmed this documentation was not available during this inspection.
Evidence:
1. The record for child #3(enrolled 12/4/23) did not contain the required written agreements.
2. Staff confirmed this documentation was not available during this inspection.
Plan of Correction: Written agreements between the parents and the center will be obtained for child #3and added to the child?s file.