Inspection · 2023-05-24
Date
2023-05-24
Complaint Related
No
Licensing Inspector
Sarah Marbert
(703) 479-4678
(703) 479-4678
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
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted on 5/24/2023 from 10:05am to 2:00pm. At the time of entrance, 60 children were in care with 11 staff members present. Children were observed washing hands, eating lunch, playing outside, preparing for nap time and sleeping on cots. Infants were observed being held, sitting and sleeping in bouncy seats and sleeping in a crib. A selection of staff and children records, medications, the physical space, evacuation drills, emergency supplies and attendance records were reviewed. Areas of non-compliance are identified in the violation notice. Please contact me if you have any questions at Stacy.Doyle@doe.virginia.gov or 571-835-0386.
Violations
18Standard 22.1-289.058
Based on observation and interview, the center was not equipped with at least one carbon monoxide detector.
Evidence:
1. A carbon monoxide detector was not observed in the center.
2. Staff #4 stated she did not know if they had a carbon monoxide detector and would call to find out if they did.
Evidence:
1. A carbon monoxide detector was not observed in the center.
2. Staff #4 stated she did not know if they had a carbon monoxide detector and would call to find out if they did.
Plan of Correction: carbon monoxide detector was purchased and placed in the center.
Standard 8VAC20-780-130-E
Based on review of children's records, the center did not obtain documentation of additional immunizations once every six months for children under the age of two years.
Evidence:
1. Child #1 (19 months) had immunization record updated last on 7/20/2022 and was due for an update.
Evidence:
1. Child #1 (19 months) had immunization record updated last on 7/20/2022 and was due for an update.
Plan of Correction: requested updated immunization records from student.
Standard 8VAC20-780-180-A
Based on observation, one staff did not meet a general qualification of communicating effectively orally.
Evidence:
1. Staff B who works in the infant classroom did not demonstrate the ability to speak English.
Evidence:
1. Staff B who works in the infant classroom did not demonstrate the ability to speak English.
Plan of Correction: staff will practice speaking in English with peers she is also looking to enroll in English classes.
Standard 8VAC20-780-240-C
Based on review of the orientation document, the center's orientation did not include all requirement topics.
Evidence:
1. Staff #1 (Date of hire 3/07/2022) and Staff #2 (Date of hire 8/22/2022) had orientation, but it did not include prevention of sudden infant death syndrome and use of safe sleep practices or prevention of shaken baby syndrome and abusive head trauma, including
procedures to cope with crying babies or distraught children.
Evidence:
1. Staff #1 (Date of hire 3/07/2022) and Staff #2 (Date of hire 8/22/2022) had orientation, but it did not include prevention of sudden infant death syndrome and use of safe sleep practices or prevention of shaken baby syndrome and abusive head trauma, including
procedures to cope with crying babies or distraught children.
Plan of Correction: Printed and viewed updated orientation document provided by license inspector with all staff. We have included additional training that highlights the prevention of sudden infant death syndrome and safe sleep, shaken baby syndrome.
Standard 8VAC20-780-240-E
Based on interview and review of training, two staff did not complete orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care within 30 days of the first day of employment.
Evidence:
1. Staff #1 (Date of hire 3/07/2022) and Staff #2 (Date of hire 8/22/2022) did not have documentation that the training in first aid and cardiopulmonary resuscitation (CPR) had been given.
2. Staff #4 stated she did not know the training was required.
Evidence:
1. Staff #1 (Date of hire 3/07/2022) and Staff #2 (Date of hire 8/22/2022) did not have documentation that the training in first aid and cardiopulmonary resuscitation (CPR) had been given.
2. Staff #4 stated she did not know the training was required.
Plan of Correction: make sure orientation covers first aid and cpr training according to age group.
Standard 8VAC20-780-260-A
Based on interview, the center did not provide to the licensing representative an annual fire inspection report.
Evidence:
1. Staff A stated the inspection was completed, but did not have a copy of the report.
Evidence:
1. Staff A stated the inspection was completed, but did not have a copy of the report.
Plan of Correction: will follow up with the City fire marshall to obtain our annual inspection.
Standard 8VAC20-780-270-A
Based on observation and interviews, areas and equipment inside the center were not maintained in a safe and operable condition.
Evidence:
1. In the Pre-K 4's classroom, the paint was chipping on the molding near the trashcan.
2. In the infant classroom, the refrigerator was not working (teachers were using the kitchen refrigerator to store the bottles) and paint was chipping around the trim molding.
3. In the young toddler classroom, staff stated the sink was broken and not working.
4. In the older infant classroom, the cabinet near the refrigerator had a loose hinge and was hanging crooked.
5. In the main hallway bathroom, staff stated the toilet was broken and not working.
6. In the Toddler 2's classroom, staff stated the sink was broken and not working. The rugs border had come unsewn or had torn approximately 24 inches long and was creating a tripping hazard. The red children's chairs were peeling paint on the legs and had rust on them.
Evidence:
1. In the Pre-K 4's classroom, the paint was chipping on the molding near the trashcan.
2. In the infant classroom, the refrigerator was not working (teachers were using the kitchen refrigerator to store the bottles) and paint was chipping around the trim molding.
3. In the young toddler classroom, staff stated the sink was broken and not working.
4. In the older infant classroom, the cabinet near the refrigerator had a loose hinge and was hanging crooked.
5. In the main hallway bathroom, staff stated the toilet was broken and not working.
6. In the Toddler 2's classroom, staff stated the sink was broken and not working. The rugs border had come unsewn or had torn approximately 24 inches long and was creating a tripping hazard. The red children's chairs were peeling paint on the legs and had rust on them.
Plan of Correction: We have ordered new portable sinks for all toddler classes.
1. classrooms with chipped paint will get a fresh coat of paint.
2. new refrigerator has been purchased and replaced.
3. sink has been purchased.
4. loose hinge has been fixed.
5. maintenance came out to unclog the middle toilet.
6. new sink has been purchased, new chairs have been purchased, area rug has been discarded.
1. classrooms with chipped paint will get a fresh coat of paint.
2. new refrigerator has been purchased and replaced.
3. sink has been purchased.
4. loose hinge has been fixed.
5. maintenance came out to unclog the middle toilet.
6. new sink has been purchased, new chairs have been purchased, area rug has been discarded.
Standard 8VAC20-780-280-B
Based on observation, hazardous substances such as cleaning materials were not kept in a locked place using a safe locking method.
Evidence:
1. In the older infants classroom, a Lysol spray, febreeze and disinfectant spray were inside a higher cabinet and was not kept locked. The child proof lock was hanging on the handle and not engaged.
Evidence:
1. In the older infants classroom, a Lysol spray, febreeze and disinfectant spray were inside a higher cabinet and was not kept locked. The child proof lock was hanging on the handle and not engaged.
Plan of Correction: reiterated importance of locking hazardous substances when not in use with all staff.
Standard 8VAC20-780-340-D
Based on observation and interview, the center did not have a program leader regularly present in each grouping of children.
Evidence:
1. Staff #4 stated they did not have program leaders in three classrooms(Toddler 1 classroom, Toddler 2 classroom or the Infant classroom).
Evidence:
1. Staff #4 stated they did not have program leaders in three classrooms(Toddler 1 classroom, Toddler 2 classroom or the Infant classroom).
Plan of Correction: we are providing ample resources and support for teachers to be able to obtain lead teacher qualifications.
Standard 8VAC20-780-340-F
Based on observation, children under 10 years of age were not always within actual sight and sound supervision of staff.
Evidence:
1. One child was observed entering the 3's classroom by herself. The licensing representative took the child back to join her class in the hallway where they were waiting to wash their hands in the bathroom.
2. Four children were observed running from the Toddler teacher in the hallway and entered the classroom without the teacher. The teacher was assisting a child with washing their
hands and not aware the 4 children had run away.
Evidence:
1. One child was observed entering the 3's classroom by herself. The licensing representative took the child back to join her class in the hallway where they were waiting to wash their hands in the bathroom.
2. Four children were observed running from the Toddler teacher in the hallway and entered the classroom without the teacher. The teacher was assisting a child with washing their
hands and not aware the 4 children had run away.
Plan of Correction: Management is properly training staff to line students up and do a head count upon leaving the classroom and returning as well as when in the hallway and throughout the day.
Standard 8VAC20-780-40-K
Based on interview and review of documents, the center did not develop written procedures for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness.
Evidence:
1. Staff #4 confirmed the center did not have written procedure for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness during the inspection.
Evidence:
1. Staff #4 confirmed the center did not have written procedure for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness during the inspection.
Plan of Correction: We have developed a written procedure for shaken baby syndrome and abusive head trauma, including copying with crying babies, safe sleep practices and SIDS.
Standard 8VAC20-780-420-E-3
Based on review of children's records, one child's file did not have the parent confirmation that the required information in the child's record was up to date annually.
Evidence:
1. Child #1's file (Start date 3/21/2022) did not have yearly parent confirmation that the required information in the child's record was up to date.
Evidence:
1. Child #1's file (Start date 3/21/2022) did not have yearly parent confirmation that the required information in the child's record was up to date.
Plan of Correction: request parents to update students annual information.
Standard 8VAC20-780-440-L
Based on observation, pillows were used by children under two years of age.
Evidence:
1. A child (4 months old) in the infant classroom was observed laying in a crib with their head propped and surrounded by a boppy pillow.
Evidence:
1. A child (4 months old) in the infant classroom was observed laying in a crib with their head propped and surrounded by a boppy pillow.
Plan of Correction: We have readdressed the prohibition usage of pillows in cribs.
Standard 8VAC20-780-500-B
Based on observation and interview, the center did not meet all diapering requirements.
Evidence:
1. The foot operated trash can used to dispose of diapers was broken. The pedal did not work. The teacher stated it broke yesterday.
Evidence:
1. The foot operated trash can used to dispose of diapers was broken. The pedal did not work. The teacher stated it broke yesterday.
Plan of Correction: Broken trash can has been thrown out and replaced.
Standard 8VAC20-780-560-F
Based on observation, the center provides meals and snacks and did not follow the most recent, age-appropriate nutritional requirements of the Child and Adult Care Food Program of the United States Department of Agriculture (USDA), and the center's menu listing foods to be served for meals and snacks during the current one-week period was not posted in a location conspicuous to parents or given to parents.
1. A menu was posted in classrooms, but it did not include all the foods being served. The menu only listed the entree. A full menu from the caterer was inside the kitchen.
2. Lunch on 5/24/2023 consisted of a ground beef patty, cantelope, carrots and milk. The bun was not delivered by the food caterer, so there was not a grain provided for lunch.
1. A menu was posted in classrooms, but it did not include all the foods being served. The menu only listed the entree. A full menu from the caterer was inside the kitchen.
2. Lunch on 5/24/2023 consisted of a ground beef patty, cantelope, carrots and milk. The bun was not delivered by the food caterer, so there was not a grain provided for lunch.
Plan of Correction: post full menu provided from the catering company in each classroom. staff member signing off when received lunch from the catering company must double check to ensure all menu items have been delivered.
Standard 8VAC20-780-560-G
Based on observation and interviews, food brought from home was not clearly dated and labeled in a way that identifies the owner.
Evidence:
1. In the older infant classroom, 3 pouches of food and 2 containers of food were inside the classroom refrigerator and were not dated or labeled to identify the owner.
2. The staff stated the food was brought from home by the children.
Evidence:
1. In the older infant classroom, 3 pouches of food and 2 containers of food were inside the classroom refrigerator and were not dated or labeled to identify the owner.
2. The staff stated the food was brought from home by the children.
Plan of Correction: reiterated that all bottles, snacks and lunch be labeled with students name and date.
Standard 8VAC20-780-570-B
Based on observation, bottle fed infants were given bottles propped and given when the child was in his designated sleeping location.
Evidence:
1. One infant (4 months old) was observed sitting in an infant swing with the bottle propped with a blanket.
2. One infant(4 months old) was observed laying in a crib with a bottle next to the child.
Evidence:
1. One infant (4 months old) was observed sitting in an infant swing with the bottle propped with a blanket.
2. One infant(4 months old) was observed laying in a crib with a bottle next to the child.
Plan of Correction: educate/train teachers on proper feeding mannerism.
Standard 8VAC20-780-70
Based on record review, staff records did not include all required information.
Evidence:
1. Staff #1's file (Date of hire 3/07/2022) did not have documentation to demonstrate that the individual possesses the 24 hours of training required by the job position (Lead Teacher).
Evidence:
1. Staff #1's file (Date of hire 3/07/2022) did not have documentation to demonstrate that the individual possesses the 24 hours of training required by the job position (Lead Teacher).
Plan of Correction: Staff #1 will bring in the 24 hour certification to be a lead teacher.