Inspection · 2022-06-02
Date
2022-06-02
Complaint Related
No
Licensing Inspector
Cindy Horne
(804) 297-4469
(804) 297-4469
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced renewal inspection was conducted on June 2, 2022. The director was available during the inspection. There were 54 children present, ranging in ages from 3 years to 7 years, with 8 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 5 child records, 5 staff records, and 2 board member 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
16Standard 22.1-289.035-B-2
ased on a review of records and interview on June 2, 2022, the center did not ensure to obtain a fingerprint based national criminal record check prior to the first day of employment for each staff.
Evidence: The record of staff #5 (hired 12/21/21) contained documentation of fingerprints dated 9/4/19. During interview, administration reported staff #5 was previously employed at the center but ended employment in January 2021. Staff #5 was rehired on 12/21/21 but new fingerprints were not completed prior to the first day of employment.
Evidence: The record of staff #5 (hired 12/21/21) contained documentation of fingerprints dated 9/4/19. During interview, administration reported staff #5 was previously employed at the center but ended employment in January 2021. Staff #5 was rehired on 12/21/21 but new fingerprints were not completed prior to the first day of employment.
Plan of Correction: *Note - an immediate need for an Interim became actionable on Dec. 20th, thus the re-hire (not considered a rehire by RWS policy as within 12 months of leaving 1/15/21.
1. Will immediately begin using the Staff Hire Check List provided by DSS in process for hiring staff applicable for VDOE-DSS license.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
1. Will immediately begin using the Staff Hire Check List provided by DSS in process for hiring staff applicable for VDOE-DSS license.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
Standard 22.1-289.035-B-4
Based on a review of records on June 2, 2022,the center did not obtain results of a check of the out-of-state criminal history record check and out-of-state sex offender registry prior to employment for each employee and did not request an out-of-state search of the child abuse and neglect registry or equivalent by the end of the 30th day of employment for each employee who has resided in any other state in the preceding five years.
Evidence: 1. The record of staff #1 (hired 4/5/22) did not contain documentation of an out-of-state child abuse and neglect registry search. Staff #1 identified as living in another state in the previous five years on the staff's sworn disclosure statement.
2. The record of staff #4 (hired 1/13/22) did not contain documentation of an out-of-state sex offender, criminal name search, or search of the child abuse and neglect registry. Staff #4 identified as living in another state in the previous five years on the staff's sworn disclosure statement.
Evidence: 1. The record of staff #1 (hired 4/5/22) did not contain documentation of an out-of-state child abuse and neglect registry search. Staff #1 identified as living in another state in the previous five years on the staff's sworn disclosure statement.
2. The record of staff #4 (hired 1/13/22) did not contain documentation of an out-of-state sex offender, criminal name search, or search of the child abuse and neglect registry. Staff #4 identified as living in another state in the previous five years on the staff's sworn disclosure statement.
Plan of Correction: 1. Will immediately begin using the Staff Hire Check List provided by DSS in process for hiring staff applicable for VDOE-DSS license.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
Standard 22.1-289.058
Based on an interview with administration on June 2, 2022, the center did not ensure that child day programs in a building built before 2015 that serve preschool-age children shall be equipped with at least one carbon monoxide detector.
Evidence: 1. Administration confirmed the center was built prior to 2015. 2. Administration stated they did not have a carbon monoxide detector.
Evidence: 1. Administration confirmed the center was built prior to 2015. 2. Administration stated they did not have a carbon monoxide detector.
Plan of Correction: 1. Acknowledged oversight
2.Carbon Monoxide Detector to be installed week of 6/20/22.
3. Director of Administration or Interim Director of Administration, Facilities Coordinator.
2.Carbon Monoxide Detector to be installed week of 6/20/22.
3. Director of Administration or Interim Director of Administration, Facilities Coordinator.
Standard 8VAC20-780-160-A-2
Based on a review of staff records on June 2, 2022, the center did not ensure each staff member completed tuberculosis screening within the last 30 calendar days prior to beginning employment.
Evidence: The record of staff #5 (hired 12/21/21) contained documentation of a tuberculosis screening dated 9/5/19.
Evidence: The record of staff #5 (hired 12/21/21) contained documentation of a tuberculosis screening dated 9/5/19.
Plan of Correction: 1.Acknowledged oversight.
2.Review of all staff pre-hire requirements underway to be completed 6/22/22 to ensure compliance.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator
2.Review of all staff pre-hire requirements underway to be completed 6/22/22 to ensure compliance.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator
Standard 8VAC20-780-240-I
Based on a review of records and interview on June 2, 2022, the center did not ensure that documentation of orientation training shall be kept by the center in a manner that allows for identification by individual staff member, is considered part of the staff member's record.
Evidence: The records of staff #1 (hired 4/5/22), staff #2 (hired 2/21/22), and staff #3 (hired 10/20/21) did not contain documentation of orientation. Administration acknowledged the documentation was not in the files.
Evidence: The records of staff #1 (hired 4/5/22), staff #2 (hired 2/21/22), and staff #3 (hired 10/20/21) did not contain documentation of orientation. Administration acknowledged the documentation was not in the files.
Plan of Correction: 1. Will immediately begin using the Staff Hire Check List provided by DSS in process for hiring staff applicable for VDOE-DSS license.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
Standard 8VAC20-780-245-L
Based on an interview with administration on June 2, 2022, the center did not ensure there is always at least one staff member on duty who has obtained within the last three years, instruction in performing the daily health observation of children.
Evidence: When asked about daily health observation, administration stated that no one at the center has obtained instruction on the daily health observation of children.
Evidence: When asked about daily health observation, administration stated that no one at the center has obtained instruction on the daily health observation of children.
Plan of Correction: 1. Unaware of the changing and updating of licensing requirements and acknowledging change over of 3 Administrators within 11 months has created inconsistent oversight.
2. Staff will be trained with paper documents by 6/22/22 and in person upon return to school 8/19/22.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair.
2. Staff will be trained with paper documents by 6/22/22 and in person upon return to school 8/19/22.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair.
Standard 8VAC20-780-270-A
Based on observation, the center did not ensure that areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition.
Evidence: 1. A knife with an approximate 5 inch blade was located in a caddy outside on the table where the children eat snack. Several children were observed playing unsupervised near the table with the knife. The knife was within reach of children ages 4-7 years old. 2. In the Magnolia classroom there was a butcher knife in an unlocked cabinet accessible to children.
Evidence: 1. A knife with an approximate 5 inch blade was located in a caddy outside on the table where the children eat snack. Several children were observed playing unsupervised near the table with the knife. The knife was within reach of children ages 4-7 years old. 2. In the Magnolia classroom there was a butcher knife in an unlocked cabinet accessible to children.
Plan of Correction: 1.Acknowledged. Waldorf Education includes life skills starting in Early Childhood and the proper use of kitchen and garden implements.
2. Staff acknowledged immediately the day of the Inspection and accepts evidence.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair.
2. Staff acknowledged immediately the day of the Inspection and accepts evidence.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair.
Standard 8VAC20-780-280-B
Based on observation, 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. In the Dogwood classroom there were disinfectant wipes and Goo-Gone in an unlocked cabinet under the sink. The label on the disinfectant wipes stated "keep out of reach of children" and "caution." The label on the Goo-Gone stated "keep out of reach of children" and "danger and fatal."
2. In the Oak classroom there was Re-Juv-Nal cleaner left out on a counter and unlocked. The label on the Re-Juv-Nal stated "keep out of the reach of children" and "danger."
3. In the Magnolia classroom there were several cleaners to include Resolve, Chlorox, Re-Juv-Nal, and AirScents in an unlocked cabinet. The label of the Resolve stated "keep out of reach of children" and "warning." The label of the Chlorox stated "keep out of reach of children" and "warning." The label of the Re-Juv-Nal stated "keep out of reach of children" and "danger." The label on the AirScents stated "keep out of reach of children" and "caution."
Evidence: 1. In the Dogwood classroom there were disinfectant wipes and Goo-Gone in an unlocked cabinet under the sink. The label on the disinfectant wipes stated "keep out of reach of children" and "caution." The label on the Goo-Gone stated "keep out of reach of children" and "danger and fatal."
2. In the Oak classroom there was Re-Juv-Nal cleaner left out on a counter and unlocked. The label on the Re-Juv-Nal stated "keep out of the reach of children" and "danger."
3. In the Magnolia classroom there were several cleaners to include Resolve, Chlorox, Re-Juv-Nal, and AirScents in an unlocked cabinet. The label of the Resolve stated "keep out of reach of children" and "warning." The label of the Chlorox stated "keep out of reach of children" and "warning." The label of the Re-Juv-Nal stated "keep out of reach of children" and "danger." The label on the AirScents stated "keep out of reach of children" and "caution."
Plan of Correction: 1. Acknowledged oversight
2.Staff advised of evidence and will correct as soon as possible along with the Facilities Coordinator and contracted Cleaning Co. Training for all staff required by license will be held when all employees return by 8/19/22.
3 Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, Facilities Coordinator.
2.Staff advised of evidence and will correct as soon as possible along with the Facilities Coordinator and contracted Cleaning Co. Training for all staff required by license will be held when all employees return by 8/19/22.
3 Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, Facilities Coordinator.
Standard 8VAC20-780-340-F
Based on observation and interview on June 2, 2022, the center failed to ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff.
Evidence: During the inspection child #3 (age 4) was observed walking alone from the restroom inside the center to return to her class that was on the playground. Child #3 was not within in sight and sound of staff. Staff confirmed the child came from the restroom unsupervised.
Evidence: During the inspection child #3 (age 4) was observed walking alone from the restroom inside the center to return to her class that was on the playground. Child #3 was not within in sight and sound of staff. Staff confirmed the child came from the restroom unsupervised.
Plan of Correction: 1.Acknowledged oversight
2.Staff immediately acknowledged and will correct by training by 8/19/22 when all employees return.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair
2.Staff immediately acknowledged and will correct by training by 8/19/22 when all employees return.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair
Standard 8VAC20-780-500-A
Based on interview on June 2, 2022, the center did not ensure that children wash their hands with soap and running water or disposable wipes after eating meals or snacks.
Evidence: Staff stated that children do not wash their hands after snack.
Evidence: Staff stated that children do not wash their hands after snack.
Plan of Correction: 1.Acknowledged oversight
2.Staff immediately acknowledged and will correct by training by 8/19/22 when all employees return.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair
2.Staff immediately acknowledged and will correct by training by 8/19/22 when all employees return.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair
Standard 8VAC20-780-510-E
Based on an interview with administration on June 2, 2022, the center did not ensure procedures for administering medication include methods to prevent use of outdated medication.
Evidence: When asked for the center's medication procedures administration stated they did not have documentation of procedures to include methods to prevent use of outdated medication.
Evidence: When asked for the center's medication procedures administration stated they did not have documentation of procedures to include methods to prevent use of outdated medication.
Plan of Correction: 1.Acknowledged oversight.
2.Document created to address Medication administration and training by 6/23/22.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
2.Document created to address Medication administration and training by 6/23/22.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
Standard 8VAC20-780-550-D
Based on a review of records and interview on June 2, 2022, the center did not ensure to implement a minimum of two shelter-in-place practice drills per year for the most likely to occur scenarios.
Evidence: Documentation of shelter-in-place drills indicated only one drill was practiced in 2021. Administration confirmed only one drill was completed.
Evidence: Documentation of shelter-in-place drills indicated only one drill was practiced in 2021. Administration confirmed only one drill was completed.
Plan of Correction: 1. Acknowledged oversight.
2.Correction will be made to ensure Shelter in Place Drills for the 2022-2023 Academic year. The requirement is in the Emergency Response Manual.
2. Director of Administration or Interim Director of Administration, Facilities Coordinator, Administrative Coordinator
2.Correction will be made to ensure Shelter in Place Drills for the 2022-2023 Academic year. The requirement is in the Emergency Response Manual.
2. Director of Administration or Interim Director of Administration, Facilities Coordinator, Administrative Coordinator
Standard 8VAC20-780-560-J
Based on interview on June 2, 2022, the center did not ensure tables are sanitized before and after each use for feeding.
Evidence: 1. Two staff in two different classrooms stated that tables aren't being sanitized before and after snack.
Evidence: 1. Two staff in two different classrooms stated that tables aren't being sanitized before and after snack.
Plan of Correction: 1. Acknowledged oversight.
2. Staff reminded of requirements in writing 6/21/22.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair
2. Staff reminded of requirements in writing 6/21/22.
3. Director of Administration or Interim Director of Administration, Early Childhood Lead Teacher, College Chair
Standard 8VAC20-780-60-A
Based on a review of records on June 2, 2022, the center did not ensure that each child's record contained the required information.
Evidence: 1. The record of child #2 (enrolled 9/1/22) did not contain documentation of parent agreements, the name, address, and phone number of two people to call in an emergency, and names of persons authorized to pick up the child.
2. The record of child #4 (enrolled 8/26/22) did not contain documentation of immunizations and a physical.
Evidence: 1. The record of child #2 (enrolled 9/1/22) did not contain documentation of parent agreements, the name, address, and phone number of two people to call in an emergency, and names of persons authorized to pick up the child.
2. The record of child #4 (enrolled 8/26/22) did not contain documentation of immunizations and a physical.
Plan of Correction: 1. Will immediately begin using the Staff Hire Check List provided by DSS in process for hiring staff applicable for VDOE-DSS license.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
Standard 8VAC20-780-70
Based on a review of staff records on June 2, 2022, the center did not ensure that two or more references were checked before employment.
Evidence: 1. The records of staff #1 (hired 4/5/22), staff #2 (hired 2/21/22), and staff #4 (hired 1/13/22) did not contain documentation of references.
Evidence: 1. The records of staff #1 (hired 4/5/22), staff #2 (hired 2/21/22), and staff #4 (hired 1/13/22) did not contain documentation of references.
Plan of Correction: 1. Will immediately begin using the Staff Hire Check List provided by DSS in process for hiring staff applicable for VDOE-DSS license.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
Standard 8VAC20-820-120-E-2
Based on observation and interview on June 2, 2022, the center did not ensure the findings of the most recent inspection were posted in the facility.
Evidence: The findings from the most recent inspection conducted April 15, 2021 were not posted in the facility on the date of inspection.
Evidence: The findings from the most recent inspection conducted April 15, 2021 were not posted in the facility on the date of inspection.
Plan of Correction: 1. Will immediately begin using the Staff Hire Check List provided by DSS in process for hiring staff applicable for VDOE-DSS license.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.
2. Process begun to have all documents processed by July 1, 2022.
3. Director of Administration or Interim Director of Administration, Administrative Coordinator.