Inspection · 2023-09-11
Date
2023-09-11
Complaint Related
No
Licensing Inspector
Trisha Brown
(757) 404-2601
(757) 404-2601
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.
8VAC20-820 HEARINGS PROCEDURES.
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 and concluded on September 11, 2023. There were 55 children in care ages four through 12 years old with five staff. Children were observed in teacher and self-directed activities. Children's records were reviewed onsite along with available staff emergency contact information. Staff records were reviewed at the central location on the same day. Violations regarding children's records, staff records and supervision were observed and appear on the violation notice. The violations were discussed with the administrator on site during the exit interview at the conclusion of the inspection.
Violations
7Standard 8VAC20-780-130-A
Based on record review the center failed to obtain documentation that each child has received the required immunizations.
Evidence:
1 - The record for Child #1 does not contain documentation that all required immunizations were obtained as only page two of a two page document was visible in the digital record.
2 - Staff #1 confirmed that only page 2 was of a 2 page document was available in the digital record.
Evidence:
1 - The record for Child #1 does not contain documentation that all required immunizations were obtained as only page two of a two page document was visible in the digital record.
2 - Staff #1 confirmed that only page 2 was of a 2 page document was available in the digital record.
Plan of Correction: Families will be required to complete
all required paperwork by the
Wednesday prior to the child's care
beginning or they will be removed
from the program.
All current families have until
10/11/23 to get paperwork submitted
or the child will be removed from the
program.
all required paperwork by the
Wednesday prior to the child's care
beginning or they will be removed
from the program.
All current families have until
10/11/23 to get paperwork submitted
or the child will be removed from the
program.
Standard 8VAC20-780-140-A
Based on record review and interview the center failed to obtain documentation of a physical examination as required.
Evidence:
1 - The digital record of Child #1 did not contain documentation of physical examination.
2 - Staff #1 confirmed that the digital record of Child #1 did not contain documentation of a physical examination.
Evidence:
1 - The digital record of Child #1 did not contain documentation of physical examination.
2 - Staff #1 confirmed that the digital record of Child #1 did not contain documentation of a physical examination.
Plan of Correction: Families will be required to complete
all required paperwork by the
Wednesday prior to the child's care
beginning or they will be removed
from the program.
All current families have until
10/11/23 to get paperwork submitted
or the child will be removed from the
program.
all required paperwork by the
Wednesday prior to the child's care
beginning or they will be removed
from the program.
All current families have until
10/11/23 to get paperwork submitted
or the child will be removed from the
program.
Standard 8VAC20-780-160-A
Based on record review and interview the center failed to obtain documentation of a negative tuberculosis screening within required time frames.
Evidence:
1 - The record for Staff #5 did not contain documentation of a tuberculosis screening
2 - Staff #5 was present providing direct to children during the inspection.
3 - Staff #6 confirmed there was not documentation of tuberculosis screening in the record for Staff #5 in the central records.
Evidence:
1 - The record for Staff #5 did not contain documentation of a tuberculosis screening
2 - Staff #5 was present providing direct to children during the inspection.
3 - Staff #6 confirmed there was not documentation of tuberculosis screening in the record for Staff #5 in the central records.
Plan of Correction: All staff will be required to get
their TB screening prior to their
first day on the floor.
Staff needing to get their TB test
will complete that immediately.
their TB screening prior to their
first day on the floor.
Staff needing to get their TB test
will complete that immediately.
Standard 8VAC20-780-240-A
Based on record review and interview the center failed to ensure that staff complete required department training within 90 days of employment.
Evidence:
1 - The record for Staff #3 did not contain any documentation that the required department training had been completed.
2 - Staff #6 confirmed that the documentation of having completed the departments required training was not present in the record of Staff #3 during the central record review.
Evidence:
1 - The record for Staff #3 did not contain any documentation that the required department training had been completed.
2 - Staff #6 confirmed that the documentation of having completed the departments required training was not present in the record of Staff #3 during the central record review.
Plan of Correction: All staff will complete the required
trainings and it will be properly
documented in their staff file by the
Youth Development Director.
trainings and it will be properly
documented in their staff file by the
Youth Development Director.
Standard 8VAC20-780-340-A
Based on observation when supervising children the center failed to ensure their care, protection and guidance.
Evidence:
1 - Staff did not intervene when on multiple occasions between 3:30pm and 5pm children engaged in unsafe activities including hitting and pushing each other, swinging arms and backpacks at each other, climbing on chairs and chasing each other around the cafeteria tables.
a.Staff only intervened when instructed to do so.
Evidence:
1 - Staff did not intervene when on multiple occasions between 3:30pm and 5pm children engaged in unsafe activities including hitting and pushing each other, swinging arms and backpacks at each other, climbing on chairs and chasing each other around the cafeteria tables.
a.Staff only intervened when instructed to do so.
Plan of Correction: Staff at the site have been
retrained on behavior guidance.
This topic has also been added
to our November all staff training
agenda.
retrained on behavior guidance.
This topic has also been added
to our November all staff training
agenda.
Standard 8VAC20-780-360-A
Based on observation the center failed to provide age and stage appropriate activities for all age groups.
1 - From 3:30pm through 4:45pm there were not any organized activities available for children in grades first through fourth.
2 - Staff #1 stated that it was difficult to provide activities with such a large group of children.
1 - From 3:30pm through 4:45pm there were not any organized activities available for children in grades first through fourth.
2 - Staff #1 stated that it was difficult to provide activities with such a large group of children.
Plan of Correction: A schedule of activities and rotations
have been created for the entirety of
the afternoon. Students rotate
through snack/meal, gym time,
curriculum, free play, etc.
have been created for the entirety of
the afternoon. Students rotate
through snack/meal, gym time,
curriculum, free play, etc.
Standard 8VAC20-780-70
Based on record review and interview the center failed to maintain staff records as required.
Evidence:
1 - There was not any onsite record for Staff #1 or #2. Both staff present providing direct care to children during the inspection.
2 - Additionally, the record for Staff #2, #4 and #5 did not contain documentation of date of hire.
3 - Staff #6 confirmed that this information was not documented in records at the central location.
4 Staff #1 confirmed that emergency contact information was not available onsite as required.
Evidence:
1 - There was not any onsite record for Staff #1 or #2. Both staff present providing direct care to children during the inspection.
2 - Additionally, the record for Staff #2, #4 and #5 did not contain documentation of date of hire.
3 - Staff #6 confirmed that this information was not documented in records at the central location.
4 Staff #1 confirmed that emergency contact information was not available onsite as required.
Plan of Correction: All staff will be required to
complete the onsite orientation
checklist which includes their
emergency contacts.
Youth Development Directors
will make sure all staff files
include the hire date.
complete the onsite orientation
checklist which includes their
emergency contacts.
Youth Development Directors
will make sure all staff files
include the hire date.