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Alicia Villagra

Inspection · 2024-08-07

Date
2024-08-07
Complaint Related
No
Licensing Inspector
Sarah Zirzow
(703) 479-4675
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

8VAC20-800 Administration
8VAC20-800 Personnel
8VAC20-800 Household Members
8VAC20-800 Physical Health of Caregivers and Household members
8VAC20-800 Caregiver Training
8VAC20-800 Physical Equipment and Environment
8VAC20-800 Care of Children
8VAC20-800 Preventing the Spread of Disease
8VAC20-800 Medication Administration
8VAC20-800 Emergencies
8VAC20-800 Nutrition
8VAC20-800 Transportation
8VAC20-800 Nighttime Care
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
54.1 Provider must be MAT certified to administer prescription medication.
63.2 Child abuse and neglect

Inspector Notes

An unannounced, on-site renewal inspection was initiated and completed on August 7, 2024, as a part of the licensure period. The on-site inspection began at 10:25am and ended at 12:30pm. The inspector reviewed compliance in the areas listed above. There were 10 children present (28 points) and 2 staff. The inspector reviewed 5 children?s records and 3 staff records. This inspection included document review, tour of the facility, interviews, and observations. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.

Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on August 21, 2024. A POC submitted after this date will not appear on the public website.

Violations

10
Standard 22.1-289.011-F
REPEAT VIOLATION
Based on observation, the provider did not have the most recent violation notice and inspection summary posted.

Evidence:
The most recent violation notice and inspection summary (date of last inspection 2/6/24) was not posted.
Plan of Correction: Most recent violation notice and inspection summary is now posted.
Standard 8VAC20-800-100-A
REPEAT VIOLATION
Based on record review, the provider did not obtain documentation of a physical examination within 30 days of attendance.

Evidence:
Child #5 (date of enrollment 7/12/23) does not have a physical examination on file.
Plan of Correction: Child #5 has a physical scheduled.
Standard 8VAC20-800-120-A
Based on observation and interview, the provider did not maintain a record for each caregiver.

Evidence:
Upon arrival at approximately 10:25am, it was observed that only the provider was on-site with 10 children (28 points). The provider stated assistant #1 had an emergency and was off-site for approximately 30 minutes. The provider was observed on the telephone calling someone for assistance. Approximately 5 minutes later, assistant #2 arrived to help and then a minute later assistant #1 returned. The provider stated the person who she had called to help and who arrived was assistant #1?s daughter. The provider does not have any record or the requirements for assistant #2.
Plan of Correction: I will gather information needed to make assistant #2 my new auxiliary assistant.
Standard 8VAC20-800-120-B
Based on file review, the provider did not maintain the required information for assistants.

Evidence:
-The documentation for assistant #1 did not include verification of age, date of employment, or an emergency contact.
Plan of Correction: This has now been added to the files.
Standard 8VAC20-800-50-A
Based on document review, the provider did not keep a written record of children in attendance each day.

Evidence:
-The attendance record for 8/7/24 listed 11 children. Child #6 and Child #7 were signed in on the attendance record but were absent. Child #12 was in attendance but was not signed in.
Plan of Correction: Attendance sheet template will be updated to exclude pre-printed arrival/departure times; will be handwritten daily.
Standard 8VAC20-800-50-B
Based on record review and interview, the provider did not maintain all the required records in the home.

Evidence:
-Documentation for annual training was not available at the time of inspection.
-Documentation for substitute provider information was not available at the time of inspection.
-Rabies information for cats was not available at the time of inspection.
Plan of Correction: Annual training info and certificates are now filed. Documentation for assistant #2 is in the works. Rabies info is now on file.
Standard 8VAC20-800-570-A
Based on observation and interview, the provider exceeded the 16 point maximum.

Evidence:
Upon arrival at approximately 10:25am, it was observed that only the provider was on-site with 10 children (28 points). The provider stated assistant #1 had an emergency and was off-site for approximately 30 minutes. The provider was observed on the telephone calling someone for assistance. Approximately 5 minutes later, assistant #2 arrived to help, and then a minute later assistant #1 returned.
Plan of Correction: Assistant #2 is going to be new auxiliary assistant.
Standard 8VAC20-800-60-B
REPEAT VIOLATION
Based on record review, the provider did not obtain the required information for children?s records.

Evidence:
The record for Child #5 (date of enrollment 7/12/23) did not have the name, address, and telephone number of each parent?s place of employment.
Plan of Correction: Parents missing information is now included.
Standard 8VAC20-800-80-C
Based on record review, the provider did not document the required information for proof of age and identity.

Evidence:
-Child #1 (date of enrollment 12/26/23) did not have documentation for the date proof of age and identity was viewed and by who.
-Child #2 (date of enrollment 7/22/24) did not have documentation for the date proof of age and identity was viewed and by who.
-Child #5 (date of enrollment 7/12/23) did not have documentation for the date proof of age and identity was viewed and by who.
Plan of Correction: Documentation for this will be added for children #1, 2, 5.
Standard 8VAC20-800-840-A
Based on interview, the provider did not ensure to record child injuries or accidents sustained by a child while at the family day home.

Evidence:
The provider stated they tell the parent at pick-up time about injuries but does not record in the child?s record injuries or accidents.
Plan of Correction: New template will also include space for any injuries sustained by the children.
View original record on Virginia Department of Social Services