Inspection · 2023-07-14
Date
2023-07-14
Complaint Related
Yes
Licensing Inspector
D'Nae Goodwin
(757) 404-3063
(757) 404-3063
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.
8VAC20-820 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 conducted on 07/14/2023 in response to a complaint received in the area of standards, "Behavioral Guidance." There were 86 children present and 18 staff. A tour of the facility was conducted, in addition to a record review and interviews with staff. The Inspector reviewed 5 children?s records and 5staff records, along with any requested program records submitted by the facility to determine if required documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law and violations were documented on the violation notice issued to the program.
Violations
11Standard 8VAC20-770-60-B
Based on a record review the center did not ensure all staff had the required background checks.
Evidence:
Staff #1 (start date 05/31/2023) and Staff #2 (start date 04/17/2023) did not have documentation of having a sworn statement of affirmation.
Evidence:
Staff #1 (start date 05/31/2023) and Staff #2 (start date 04/17/2023) did not have documentation of having a sworn statement of affirmation.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-60-C-2
Based on a record review the center did not ensure all staff had the required background checks.
Evidence:
Staff #6 (date of hire 04/25/2023) did not have documentation of the results of a central registry check.
Evidence:
Staff #6 (date of hire 04/25/2023) did not have documentation of the results of a central registry check.
Plan of Correction: Administrative team will follow up on Background checks when not returned timely.
Standard 8VAC20-780-260-B
Based on a record review the center did not ensure annual approval from the health department.
Evidence: The director provided the last health inspection of the center that was dated 02/02/2022
Evidence: The director provided the last health inspection of the center that was dated 02/02/2022
Plan of Correction: Administrative Team will call and schedule health inspection by 9/1/23
Standard 8VAC20-780-270-A
Based on observation the center did not ensure all areas and equipment of the center were maintained in a safe condition.
Evidence:
1. A section of glass was broken out of the lower window on the back of one of the center's vans. The section of missing glass exposed sharp edges along its perimeter. The van was parked in front of center's property near the other vans used to transport children.
2. In the three/four year-old class there was a lighter in a cubby, in reach of children.
3. There was peeling paint on door frames throughout the building.
Evidence:
1. A section of glass was broken out of the lower window on the back of one of the center's vans. The section of missing glass exposed sharp edges along its perimeter. The van was parked in front of center's property near the other vans used to transport children.
2. In the three/four year-old class there was a lighter in a cubby, in reach of children.
3. There was peeling paint on door frames throughout the building.
Plan of Correction: Management had already cleaned glass from road and called in emergency work order prior to inspector showing up. Card board placed glass while waiting for them to fix it. Staff will ensure all personal items are locked and secured away from children. Director will follow up on Work order that has been placed for paint around the building.
Standard 8VAC20-780-280-B
Based on observation the center did not ensure hazardous substances were kept in a locked place using a safe locking method.
Evidence:
In the toddler room there were 2 cans of air fresheners on the changing table.
Evidence:
In the toddler room there were 2 cans of air fresheners on the changing table.
Plan of Correction: This was corrected during inspection and Staff will ensure all hazardous materials are locked and secured away from children
Standard 8VAC20-780-340-A
Based on observation, interviews and a record review the center did not ensure the care, protection and guidance of the children in care.
Evidence:
1 . While investigating a complaint involving inappropriate behavioral guidance of children by Staff #1 resulting in that staff member's termination from the position, the inspector requested to view Staff #1's file.
2. Upon review, the inspector asked the program director why the file did not include documentation of the Staff #1's job title, qualifications or all of the required background checks. The program director stated staff #1 was unexpectedly sent from a sister school that had a temporary closure and expected to have the staff working in the classrooms. Staff#1 was retained at the center despite not having documentation of qualifications, experience or all required background checks.
3. Staff #1 was the involved in an incident that occurred 06/22/2023 involving inappropriate
behavioral guidance of children, which resulted in termination from the position. During the time of the incident Staff #1 was responsible for supervision a group of children.
Evidence:
1 . While investigating a complaint involving inappropriate behavioral guidance of children by Staff #1 resulting in that staff member's termination from the position, the inspector requested to view Staff #1's file.
2. Upon review, the inspector asked the program director why the file did not include documentation of the Staff #1's job title, qualifications or all of the required background checks. The program director stated staff #1 was unexpectedly sent from a sister school that had a temporary closure and expected to have the staff working in the classrooms. Staff#1 was retained at the center despite not having documentation of qualifications, experience or all required background checks.
3. Staff #1 was the involved in an incident that occurred 06/22/2023 involving inappropriate
behavioral guidance of children, which resulted in termination from the position. During the time of the incident Staff #1 was responsible for supervision a group of children.
Plan of Correction: Administrative Team will ensure all files are complete before staff member is in ratio with children.
Standard 8VAC20-780-400-B
Based on observation and interview the center did not ensure staff used behavioral guidance that was constructive in nature, age and stage appropriate, and shall be intended to redirect children to appropriate behavior and resolve conflicts.
Evidence:
1. On 06/22/2023, staff #1 did not guide the behaviors of 5 year-old child #1 in a way that was constructive in nature, age and stage appropriate, and intended to redirect to appropriate behavior and resolve conflicts
a) At approximately 5:05pm video footage shows 4 children in the gym with Staff #1 and Staff #2. Child #1 hit Staff #1 with a jacket while he was seated doing paperwork.
b) Video footage shows Staff #1 get up from the seat, his mouth movements consistent with yelling, squares his shoulders and postures toward the child and began to pace the gym with clenched fists.
c) It was reported Staff #1 used a harsh tone and repeated the phrases, "I told you to stop, do not hit me."
d). A parent witness reported seeing Staff #1 exiting the gym and walking down the hallway with clenched fists and yelling, "get him out of here."
2. During the inspection on 07/14/2023 the inspector heard Staff #3 and #4 yelling from the school-age classroom on the second floor.
a) Phrases spoken with harsh and direct tones were heard such as, "I should not hear a peep," "No more toys, " and No."
b) Loud responses by children were met with louder responses by Staff #3 and #4.
c) The inspector, along with the director, walked upstairs and observed the 2 staff giving directives to the children. Neither Staff #3 or #4 gave positive redirection, aided in resolving conflict or lead the class in a way that was constructive in nature.
Evidence:
1. On 06/22/2023, staff #1 did not guide the behaviors of 5 year-old child #1 in a way that was constructive in nature, age and stage appropriate, and intended to redirect to appropriate behavior and resolve conflicts
a) At approximately 5:05pm video footage shows 4 children in the gym with Staff #1 and Staff #2. Child #1 hit Staff #1 with a jacket while he was seated doing paperwork.
b) Video footage shows Staff #1 get up from the seat, his mouth movements consistent with yelling, squares his shoulders and postures toward the child and began to pace the gym with clenched fists.
c) It was reported Staff #1 used a harsh tone and repeated the phrases, "I told you to stop, do not hit me."
d). A parent witness reported seeing Staff #1 exiting the gym and walking down the hallway with clenched fists and yelling, "get him out of here."
2. During the inspection on 07/14/2023 the inspector heard Staff #3 and #4 yelling from the school-age classroom on the second floor.
a) Phrases spoken with harsh and direct tones were heard such as, "I should not hear a peep," "No more toys, " and No."
b) Loud responses by children were met with louder responses by Staff #3 and #4.
c) The inspector, along with the director, walked upstairs and observed the 2 staff giving directives to the children. Neither Staff #3 or #4 gave positive redirection, aided in resolving conflict or lead the class in a way that was constructive in nature.
Plan of Correction: All staff have been re-trained on Positive Guidance, Classroom observation are being done weekly to coach and train staff as needed.
Standard 8VAC20-780-500-B
Based on observation the center did not ensure the diaper changing table was only used for diapering.
Evidence:
In the toddler room the diaper changing table was being used to store sunscreen, diapers and air fresheners.
Evidence:
In the toddler room the diaper changing table was being used to store sunscreen, diapers and air fresheners.
Plan of Correction: This was corrected during inspection and Staff will ensure changing tables are only used for diapering
Standard 8VAC20-780-520-B
Based on a record review the center did not ensure all requirements were met when sunscreen I used.
Evidence:
In the toddler room there was a bottle of sunscreen labeled with a child's name that did not have written authorization to apply to the child. The director confirmed the center did not have written permission from the parents.
Evidence:
In the toddler room there was a bottle of sunscreen labeled with a child's name that did not have written authorization to apply to the child. The director confirmed the center did not have written permission from the parents.
Plan of Correction: This was corrected during inspection and staff will ensure all diapers cream and sunscreen have the correct form before accepting from parents.
Standard 8VAC20-780-550-D
Based on record review the center did not have documentation of having practiced a fire drill for the months of February, March, April, May or June of 2023.
Plan of Correction: Administrative Team along with safety captain will ensure all safety drill are completed timely.
Standard 8VAC20-780-60-A
Based on a record review the center did not ensure all required information was kept for each enrolled child.
Evidence:
1. Child #1 did not have documentation of 2 required emergency contact addresses that include the name, street address, city and zip code.
2. Child #1 did not have documentation of the father's work phone number.
3. Child #2 did not have documentation of someone viewing proof of identification, not a start date of enrollment.
Evidence:
1. Child #1 did not have documentation of 2 required emergency contact addresses that include the name, street address, city and zip code.
2. Child #1 did not have documentation of the father's work phone number.
3. Child #2 did not have documentation of someone viewing proof of identification, not a start date of enrollment.
Plan of Correction: Administrative Team will ensure all files are complete during paperwork appointment prior to enrollment.