Inspection · 2022-12-19

Date

2022-12-19

Complaint Related

Licensing Inspector

Beth Orebaugh
(540) 847-9173

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 monitoring inspection was initiated on 12/19/2022 and concluded on 12/19/2022. There were 36 children present, ranging in ages from 5 years to 12 years, with 7 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 4 child records and 6 staff records were reviewed.

Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the facility.

Violations

Standard 22.1-289.035-B-2

Based on a review of staff records, the center failed to ensure that a fingerprint based national background check was completed for staff prior to employment.

Evidence:
1. Staff #1's file contained a national background check dated 06/06/2022. Date of hire for Staff #1 was 03/28/2022.
2. Staff #4's file contained a national background check dated 06/30/2021. Date of hire for Staff #4 was 07/19/2022.
3. Staff #5's file contained a national background check dated 11/03/2022. Date of hire for Staff #5 was 10/24/2022.
4. Staff #6's file contained a national background check dated 06/21/2022. Date of hire for Staff #6 was 05/31/2022.
5. Administration verified all dates of employment and confirmed all national background check dates.

Plan of Correction: New staff will not be hired prior to receiving the fingerprint background check results.

Standard 8VAC20-770-60-C-2

Based on a review of staff records and interview, the center failed to ensure that each staff record reviewed contained a central registry finding within 30 days of employment.

Evidence:
1. Staff #4's date of employment was 06/30/2021. The central registry finding on file is dated 08/14/2022.
2. Staff #6's date of employment was 05/31/2022. The central registry finding on file is dated 07/06/2022.
3. Administration confirmed the dates of employment and the date of the central registry findings on file.

Plan of Correction: Administration will be sure to complete the follow up on the central registry checks every thirty days with OBI and send them out within a timely manner once the new staff are hired.

Standard 8VAC20-780-240-B

Based on review of staff files, the center failed to ensure that staff orientation was completed prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.

Evidence:
1. Staff #1's date of hire is 03/28/2022. There is no orientation documentation on file.
2. Staff #2's date of hire is 07/1//2022. There is no orientation documentation on file.
3. Staff #3's date of hire is 08/15/2022. There is no orientation documentation on file.
4. Staff #4's date of hire is 06/30/2021, There is no orientation documentation on file.
5. Staff #5's date of hire is 10/24/2022. There is no orientation documentation on file.
6. Administration confirmed that orientation has not been completed with these staff members.

Plan of Correction: Orientation will be completed within seven days and prior to assuming job responsibilities.

Standard 8VAC20-780-550-D

Based on a review of records, the center failed to implement a monthly practice evacuation drill.

Evidence:
1. There was no documentation of Fire drills completed in August and September of 2022.
2. Administration confirmed that there was no written record if a fire drill had be completed.

Plan of Correction: The director will document every fire drill to ensure that they are completed monthly.

Standard 8VAC20-780-70

Based on a record review, the center failed to ensure that each staff record contains all the required documentation.

Evidence:
1. Staff #1, #3, and #4's file did not contain documentation that two or more references as to character and reputation as well as competency were checked prior to employment.
2. Administration confirmed that Staff #1 and Staff #3's references were late and that Staff #4 did not have any reference checks on file.

Plan of Correction: Staff references will be checked and documented prior to date of hire.

View original record on Virginia Department of Social Services