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Lutheran Church of Our Saviour

Inspection · 2023-02-15

Date
2023-02-15
Complaint Related
No
Licensing Inspector
Danielle Morrison
(804) 929-3771
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

22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
32.1 Report by person other than physician
54.1 Must be MAT Certified.
63.2 Child abuse and neglect
8VAC20-770 Background Checks
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services

Inspector Notes

An annual monitoring inspection was initiated on 02/15/2023 and concluded on 02/15/2023. The inspector was on site at the center from 10:50am to 12:15pm. There were 20 children in care with 4 staff supervising. Interviews were held with staff throughout the inspection, and the inspector interacted with children in each classroom when appropriate. The center?s playground and all classrooms were inspected today. Five children?s records and six employee records were reviewed during this inspection. Information gathered during the inspection determined areas of non-compliance with applicable regulations or law, and violations were documented on the violation notice issued to the vendor.

Violations

3
Standard 22.1-289.031-B-5
Based on observation, the center did not ensure to provide cushioning material under playground equipment.
Evidence:
There were two slides located in the playground area that did not have cushioning material.
Plan of Correction: Two moveable slides were moved to sand area.
Standard 22.1-289.035-A
Based on record review, the facility failed to obtain repeat sworn statement or affirmation for 3 of 6 staff within five years since the date of the last completed sworn statement or affirmation.
Evidence:
1. The record of staff #1 (employment date: 9/2000) had documentation of central registry results dated 9/13/17.
2. The record of staff #4 (employment date: 9/1999) had documentation of central registry results dated 9/13/17.
3. The record of staff #5 (employment date: 8/2016) had documentation of central registry results dated 7/11/16.
Plan of Correction: Statements will be emailed.
Standard 8VAC20-770-40-D-2
Based on record review, the provider did not ensure 1 of 6 staff records had documentation of central registry results within 30 days of employment.
Evidence:
1. The record of staff #2 (employment date: 8/29/2022) had documentation of central registry results dated 10/5/22.
Plan of Correction: In the future will follow up with OBI in a timely manner.