Inspection · 2024-05-30
Date
2024-05-30
Complaint Related
No
Licensing Inspector
Tameika King
(804) 629-7486
(804) 629-7486
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
8VAC20-820 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 05/30/2024 between the hours of approximately 12:40 p.m. and 2:38 p.m. There were 4 classrooms observed with a total of 62 children supervised by 8 staff members. The children were observed getting ready for nap, sleeping and infants exploring and interacting with their environment freely. Positive interaction between staff and children were observed. A complete inspection of the physical plant, children and staff records, emergency drill logs, playground and medication 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.
Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
Violations
13Standard 22.1-289.035-A
REPEAT VIOLATION
Based on record review, the center failed to obtain updated background checks every five
years for 2 out of 5 staff members.
Evidence:
1. Staff #2's most recent fingerprint results were dated 04/27/2018.
2. Staff #2's most recent central registry results were dated 07/03/2018.
3. Staff #5?s most recent fingerprint results were dated 02/26/2018.
Based on record review, the center failed to obtain updated background checks every five
years for 2 out of 5 staff members.
Evidence:
1. Staff #2's most recent fingerprint results were dated 04/27/2018.
2. Staff #2's most recent central registry results were dated 07/03/2018.
3. Staff #5?s most recent fingerprint results were dated 02/26/2018.
Plan of Correction: All staff files to be audited, missing paperwork to be completed. All pieces of paperwork stated have already been completed.
Standard 22.1-289.035-B-4
REPEAT VIOLATION
Based on record review, the center did not obtain a copy of the results of a search of the child abuse and neglect registry or equivalent registry record check for a staff member, from any state in which the individual has resided in the preceding five years.
Evidence:
1. Staff #3?s (Hire Date: 06/13/2023) sworn disclosure statement indicates that the staff
member has resided out of state in the preceding five years.
2. Staff #3?s record did not contain results of out-of-state search of the child abuse and neglect registry.
Based on record review, the center did not obtain a copy of the results of a search of the child abuse and neglect registry or equivalent registry record check for a staff member, from any state in which the individual has resided in the preceding five years.
Evidence:
1. Staff #3?s (Hire Date: 06/13/2023) sworn disclosure statement indicates that the staff
member has resided out of state in the preceding five years.
2. Staff #3?s record did not contain results of out-of-state search of the child abuse and neglect registry.
Plan of Correction: Staff member to follow up on missing out of state documents. Staff member has already been in contact with DC to ask for follow up.
Standard 8VAC20-780-130-A
Based on record review, the center did not obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center for 1 out of 6 children.
Evidence: Child #5 (start date: 3/12/2024) did not have documentation of immunizations.
Evidence: Child #5 (start date: 3/12/2024) did not have documentation of immunizations.
Plan of Correction: Missing Immunizations collected from parents and all student files audited for any missing paperwork.
Standard 8VAC20-780-140-A
Based on record review, 2 out of 6 children did not have a physical examination by or under the direction of a physician before the child's attendance or within 30 days after the first day of attendance.
Evidence:
1. Child #4 (start date: 01/02/2024) did not have documentation of a physical examination.
2. Child #5 (start date: 03/12/2024) did not have documentation of a physical examination.
Evidence:
1. Child #4 (start date: 01/02/2024) did not have documentation of a physical examination.
2. Child #5 (start date: 03/12/2024) did not have documentation of a physical examination.
Plan of Correction: Updated physicals requested from families and audit of all student files to check for any missing physicals.
Standard 8VAC20-780-150-B
Based on record review, the center did not ensure that immunization reports for 1 out of 6 children were be signed by a physician, his designee, or an official of a local health department.
Evidence: Child #4's (start date: 01/02/2024) immunization report was not signed by a physician, his designee, or an official of a local health department.
Evidence: Child #4's (start date: 01/02/2024) immunization report was not signed by a physician, his designee, or an official of a local health department.
Plan of Correction: Immunization record returned to parent to be stamped by doctor.
Standard 8VAC20-780-160-C
Based on record review, the center did not obtain a follow-up tuberculosis (TB) screening at least every two years from the date of the first initial screening or testing for 1 out of 5 staff.
Evidence: Staff #5's follow up TB screening was dated 05/09/2024. The previous TB screening was dated 09/03/21.
Evidence: Staff #5's follow up TB screening was dated 05/09/2024. The previous TB screening was dated 09/03/21.
Plan of Correction: All staff files audited to see if any screenings were due. The staff had a recent screening in their file.
Standard 8VAC20-780-270-A
REPEAT VIOLATION
Based on observation, areas of center, inside and outside, were not maintained in a clean, safe and operable condition.
Evidence:
1. There was chipped paint on the corner back wall of the Pre-K 2 classroom.
2. There was chipped paint on the wall by the diaper changing station in the Toddler room.
3. There was chipped and peeling paint on the pole of the gate located between playground 2 and the infant playground.
4. There is a circular drain on the large playground with exposed, protruding cement on its edge creating an uneven area and a potential tripping hazard.
Based on observation, areas of center, inside and outside, were not maintained in a clean, safe and operable condition.
Evidence:
1. There was chipped paint on the corner back wall of the Pre-K 2 classroom.
2. There was chipped paint on the wall by the diaper changing station in the Toddler room.
3. There was chipped and peeling paint on the pole of the gate located between playground 2 and the infant playground.
4. There is a circular drain on the large playground with exposed, protruding cement on its edge creating an uneven area and a potential tripping hazard.
Plan of Correction: Maintenance team to complete painting work in the building and on the outdoor fence. Landscape team to relay grass outside.
Standard 8VAC20-780-350-A
Based on observation of children in care, the center did not follow the maximum group size limitations of 12 for children between the ages birth up to 16 months.
Evidence:
The Toddler classroom had 13 children in care. The youngest child in care (Child #3) was 15 months old.
Evidence:
The Toddler classroom had 13 children in care. The youngest child in care (Child #3) was 15 months old.
Plan of Correction: Ratio rules to be reviewed with all staff. This was done at the staff meeting that evening and will be checked by admin on a daily basis.
Standard 8VAC20-780-350-B-1
Based on observation, the center did not follow the required ratio of 1:4 (staff:children) for children aged between birth up to 16 months, whenever children are in care.
Evidence: The toddler classroom had 13 children, including Child #3 (age: 15 months), in care during nap time with one staff member, exceeding the 1:4 ratio.
Evidence: The toddler classroom had 13 children, including Child #3 (age: 15 months), in care during nap time with one staff member, exceeding the 1:4 ratio.
Plan of Correction: Ratio rules to be reviewed with all staff. This was done at the staff meeting that evening and will be checked by admin on a daily basis.
Standard 8VAC20-780-420-E-1
REPEAT VIOLATION
Based on review of records, the daily records posted for each infant did not contain all the required information.
Evidence: Child #5's (age: 4 months) daily records on 05/16/2024, 05/17/2024, and 05/20/2024 did not contain the amount of time the child spent on their stomach.
Based on review of records, the daily records posted for each infant did not contain all the required information.
Evidence: Child #5's (age: 4 months) daily records on 05/16/2024, 05/17/2024, and 05/20/2024 did not contain the amount of time the child spent on their stomach.
Plan of Correction: All staff to be retrained on completing observations and tummy time in Tadpoles for daily log. This was completed at our monthly staff meeting that evening. It will be reviewed in training over the summer.
Standard 8VAC20-780-510-P
Based on observation and record review, when an authorization for medication expired, 3 medications that were not picked up within 14 days were not disposed of by the center.
Evidence:
1. The authorization for a medication belonging to Child #7 expired on 07/13/2023. The center did not dispose of the medication.
2. The authorization for a medication belonging to Child #8 expired in July 2023. The center did not dispose of the medication.
3. The authorization for a medication belonging to Child #9 expired on 08/22/2023. The center did not dispose of the medication.
Evidence:
1. The authorization for a medication belonging to Child #7 expired on 07/13/2023. The center did not dispose of the medication.
2. The authorization for a medication belonging to Child #8 expired in July 2023. The center did not dispose of the medication.
3. The authorization for a medication belonging to Child #9 expired on 08/22/2023. The center did not dispose of the medication.
Plan of Correction: All expired authorizations have been returned to families and appointments made to get updated forms.
Standard 8VAC20-780-520-A
REPEAT VIOLATION
Based on observation, over-the-counter skin products were kept beyond the expiration date of the product.
Evidence: A diaper cream that expired in February 2024 was kept in the Toddler room.
Based on observation, over-the-counter skin products were kept beyond the expiration date of the product.
Evidence: A diaper cream that expired in February 2024 was kept in the Toddler room.
Plan of Correction: Outdated diaper cream returned to family and replaced. All creams at center checked for expiration dates.
Standard 8VAC20-780-60-A
REPEAT VIOLATION
Based on record review, 2 out of 6 children's records did not contain all information.
Evidence:
1. Child #2's most recent documented annual update was dated 02/06/2023.
2. Child #6's most recent documented annual update was dated 09/19/2022.
Based on record review, 2 out of 6 children's records did not contain all information.
Evidence:
1. Child #2's most recent documented annual update was dated 02/06/2023.
2. Child #6's most recent documented annual update was dated 09/19/2022.
Plan of Correction: New annual updates provided to all parents to be completed ahead of Summer Camp.