Inspection · 2021-11-09

Date

2021-11-09

Complaint Related

Licensing Inspector

Heather Dapper
(804) 625-2304

Areas Reviewed

22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
22VAC40-191 Background Checks (22VAC40-191)
63.2(17) License & Registration Procedures

Inspector Notes

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, interviews and a virtual tour of the program.

A renewal inspection was initiated on November 9, 2021 and concluded on November 17, 2021. The director was contacted by telephone and a virtual inspection was conducted. There were 15 children present with 2 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 3 child records, 3 staff records were reviewed, 4 board member records, and 2 agent records were reviewed.

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.

Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days from today. Please specify how the deficient practice will be or has been corrected. Your plan of correction should 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 preventative measures. Please do not use staff names; list staff by positions only.

Violations

Standard 22VAC40-185-140-A

Based on a review of records, the center did not ensure to obtain documentation of a physical examination by or under the direction of a physician for each child before the child's attendance or within one month after attendance.
Evidence: The record of Child #1 (DOE 8/23/21) did not contain documentation of a physical.

Plan of Correction: Contact parent to request documentation of physical.

Standard 22VAC40-185-280-B

Based on observation and interview, the center did not ensure that hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children.
Evidence: 1. The center's Hillyard's Sanitizer is kept on a table on the stage in the gym. The label on the sanitizer states "keep out of reach of children" and "caution."
2. The administrator said they don't have a way to lock it up.

Plan of Correction: Connect with school about access to lock supplies in cabinet.

Standard 22VAC40-185-40-E

Based on a review of records, the center failed to comply with the center's own policies and procedures for medication.
Evidence: 1. The center's policy on medication states "if medication is found to be out-of-date, the medication must be immediately returned to the locked location. The parent/legal guardian must be informed immediately that the child did not receive their medication as scheduled. When the child is picked up that same day, the medication must be handed in person to the parent/legal guardian for their disposal. Staff are responsible for completing a medication checklist in the appendices once a month in order to stay on top of expiring medicines and authorization forms. If the medicine has expired, the staff must return the medicine to the parent."
2. The label on the medication for Child #4 stated discard after 3/30/21.

Plan of Correction: Notify parent of medication expiration, return unused items, receive new medication, and update forms.

Standard 22VAC40-185-40-G

Based on a review of records, the center did not ensure that regulated child day programs require proof of child identity and age; report to law enforcement agencies.
Evidence: The record of Child #1 (DOE 8/23/21) did not contain evidence of viewing of proof of the child's identity and age. There was no documentation of the center notifying law enforcement when proof of age and identity was not received within seven business days of initial attendance.

Plan of Correction: Contact parent to receive proof of identity.

Standard 22VAC40-185-70-A

Based on a review of records, the center did not ensure that two or more references were checked before employment.
Evidence: 1. The record of Staff #2 (DOH 10/15/21) did not contain documentation of references and orientation.
2. Administration confirmed there were no references on file. Administration said that Staff #2 did complete orientation but didn't have documentation of such.

Plan of Correction: Work with staff to get references and document orientation in timely manner.

Standard 22VAC40-191-60-C-2

Based on a review of records, the center id not ensure that each staff record reviewed contained a central registry finding within 30 days of employment.
Evidence: The record of Staff #1 (DOH 9/3/20) contained a central registry result dated 10/16/20.

Plan of Correction: Complete reviews of files prior to 30 day deadline.

Standard 63.2(17)-1720.1-B-4

Based on a review of staff records, the center did not ensure to obtain a copy of the results of a criminal history record check and sex offender registry check prior to the first day of employment from any state in which the applicant has resided in the preceding five years.
Evidence: The record of Staff #3 (DOH 8/10/20) contained documentation of sex offender registry results dated 3/19/21.

Plan of Correction: Complete record checks prior to start of employment.

View original record on Virginia Department of Social Services