Inspection · 2023-03-16
(804) 588-2368
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
A renewal inspection was conducted on 03/16/2023 from approximately 12:20 p.m. to 4:00 p.m. There were 13 children present ranging from age 6 to 10 years old and 2 staff supervising. The inspector reviewed compliance in the areas of administration, qualifications and training, physical plant, staffing and supervision, programming, medication, special care and emergencies, and nutrition. Five child (5) records and three (3) staff records were reviewed.
The information gathered during the inspection determined violations with applicable standards or law. A violation notice was issued. 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, 03/31/2023. 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 preventive measure(s). If you have any questions related to this inspection, please contact Inspector Susan Ellington-Sconiers, at 804-588-2368 or susan.ellington-sconiers@doe.virginia.gov.
Violations
11carbon monoxide detector.
Evidence:
No carbon monoxide was located in the area used by the program.
Evidence:
The record for S3, employed 06/06/2022 did not document completion of the 10-hour VDOE orientation course.
Evidence:
The fire inspection available during the inspection was dated 03/08/2022. The annual inspection should have been completed by 03/08/2023. There was no updated fire inspection available for review during the inspection.
Evidence:
The last health inspection was dated 01/12/2022. The annual inspection should have been completed by 01/12/2023. There was no updated health inspection available for review during the inspection.
Evidence:
The program director acknowledged that the injury prevention procedures had not been reviewed annually.
Evidence:
Record for S3 did not contain current certification in CPR and first aid. The record for S2 did not document certification until 03/14/2023. The program director confirmed that when S2 and S3 worked together between 01/16/2023 and 03/14/2023 no staff were CPR and first aid certified.
Evidence:
The program director was unable to locate documentation showing that the shelter in place procedures were practiced.
Based on interview, the provider failed to ensure that lockdown procedures shall be practiced at least annually.
Evidence:
The program director was unable to locate documentation showing that the lockdown procedures were practiced.
The emergency drill documentation dated October 2022 ? February 2023 did not document the weather conditions during the drills and the method used for notification of the drills.
Evidence:
Record for C2, enrolled 03/15/2023 did not document the name, address, and phone number for two emergency contacts.
Record for C3, enrolled 02/20/2023, C4, enrolled 11/08/2022, and C5, enrolled 11/08/2023 did not document proof of the child?s identity, immunizations, and physical examination (nothing in the record).
Evidence:
The records for S1, employed 09/06/2022, S2, employed 11/04/2022, S3, employed 06/06/2022 did not document information about any health problems that may interfere with fulfilling the job responsibilities.