Inspection · 2022-08-30
Date
2022-08-30
Complaint Related
No
Licensing Inspector
Nanette Roberts
(757) 404-2322
(757) 404-2322
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 renewal inspection was conducted on 8/30/2022. There were 29 children present, ranging in ages from infants to school age, with 5 staff. 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 3 child records and 5 staff 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 and discussed with the program director during the exit interview.
Violations
6Standard 8VAC20-780-130-E
Based upon review of children's records and staff interview, the facility has not ensured that they obtain documentation of additional immunizations once every six months for children under the age of two years.
Evidence:
1. The most recent immunization update in the record provided for child 3 (DOB 7/21/2021) is dated 1/24/2022.
2. Staff 1 verified that updated immunizations were not obtained for child 3.
Evidence:
1. The most recent immunization update in the record provided for child 3 (DOB 7/21/2021) is dated 1/24/2022.
2. Staff 1 verified that updated immunizations were not obtained for child 3.
Plan of Correction: The facility responded with the following:
A spreadsheet will be followed to monitor the required immunizations updates for children under the age of two years.
A spreadsheet will be followed to monitor the required immunizations updates for children under the age of two years.
Standard 8VAC20-780-160-C
Based upon review of staff records and staff interview, the facility has not ensured that staff have submitted results of tuberculosis screenings at least every two years.
Evidence:
1. The most recent tuberculosis screening in the record provided for staff 2 is dated 6/24/2019.
2. The most recent tuberculosis screening in the record provided for staff 5 is dated 9/16/2019.
3. The most recent tuberculosis screening in the record provided for staff 6 is dated 12/27/2019.
4. Staff 1 verified that more recent tuberculosis screenings had not been obtained for staff 2, 5 and 6.
Evidence:
1. The most recent tuberculosis screening in the record provided for staff 2 is dated 6/24/2019.
2. The most recent tuberculosis screening in the record provided for staff 5 is dated 9/16/2019.
3. The most recent tuberculosis screening in the record provided for staff 6 is dated 12/27/2019.
4. Staff 1 verified that more recent tuberculosis screenings had not been obtained for staff 2, 5 and 6.
Plan of Correction: The facility responded with the following:
Staff in need up updated tuberculosis screenings will be sent to the doctor as soon as possible. A tracking sheet will be used to ensure that all staff received the required tuberculosis screenings updates within every two years.
Staff in need up updated tuberculosis screenings will be sent to the doctor as soon as possible. A tracking sheet will be used to ensure that all staff received the required tuberculosis screenings updates within every two years.
Standard 8VAC20-780-350-B-1
Based upon observation, the facility has not ensured that there is one staff for every 4 infants.
Evidence:
Upon arrival of the inspector at 12:50 PM, staff 6 was supervising 3 infants, 5 young toddlers (napping) and 3 two year old children (napping). Staff 4 entered the infant classroom from her break at 12:56 PM.
Evidence:
Upon arrival of the inspector at 12:50 PM, staff 6 was supervising 3 infants, 5 young toddlers (napping) and 3 two year old children (napping). Staff 4 entered the infant classroom from her break at 12:56 PM.
Plan of Correction: The facility responded with the following:
All staff will be notified that they must remain in their assigned classrooms until relieved by another staff person. Breaks may not be taken until another staff person has taken over supervision of their group of children in that classroom.
Required ratios will be maintained at all times.
All staff will be notified that they must remain in their assigned classrooms until relieved by another staff person. Breaks may not be taken until another staff person has taken over supervision of their group of children in that classroom.
Required ratios will be maintained at all times.
Standard 8VAC20-780-350-B-2
Based upon observation, the facility has not ensured that there is one staff for every 5 young toddlers (16 mths - 2 years)..
Evidence:
Upon arrival of the inspector at 12:50 PM, staff 6 was supervising 3 infants, 5 young toddlers (napping) and 3 two year old children (napping). Staff 7, who came down from upstairs entered the young toddler classroom at 12:54 PM. Staff 7 began overseeing the 3 infants and 5 young toddlers until 12:56 PM when staff 4 returned from break and took over supervision of the 3 infants.
Evidence:
Upon arrival of the inspector at 12:50 PM, staff 6 was supervising 3 infants, 5 young toddlers (napping) and 3 two year old children (napping). Staff 7, who came down from upstairs entered the young toddler classroom at 12:54 PM. Staff 7 began overseeing the 3 infants and 5 young toddlers until 12:56 PM when staff 4 returned from break and took over supervision of the 3 infants.
Plan of Correction: The facility responded with the following:
All staff will be notified that they must remain in their assigned classrooms until relieved by another staff person. Breaks may not be taken until another staff person has taken over supervision of their group of children in that classroom.
Required ratios will be maintained at all times.
All staff will be notified that they must remain in their assigned classrooms until relieved by another staff person. Breaks may not be taken until another staff person has taken over supervision of their group of children in that classroom.
Required ratios will be maintained at all times.
Standard 8VAC20-780-350-M
Based upon observation and staff interview, the facility has not ensured that one staff member does not supervise more than one room during rest time.
Evidence:
1. Upon arrival of the inspector at 12:50 PM, staff 6 was supervising the infant room, the toddler room (napping) and the two year old room (napping) by herself.
2. Staff 6 acknowledged that she was overseeing all three classrooms and stated that staff 4 was taking out the trash and staff 7 was upstairs.
Evidence:
1. Upon arrival of the inspector at 12:50 PM, staff 6 was supervising the infant room, the toddler room (napping) and the two year old room (napping) by herself.
2. Staff 6 acknowledged that she was overseeing all three classrooms and stated that staff 4 was taking out the trash and staff 7 was upstairs.
Plan of Correction: The facility responded with the following:
All staff will be immediately notified that staff may only oversee one room of napping children.
All staff will be immediately notified that staff may only oversee one room of napping children.
Standard 8VAC20-780-550-B
Based upon review of the facility's emergency preparedness plan and staff interview, the facility has not ensured that the emergency preparedness plan contains all required procedural components.
Evidence:
1. The emergency preparedness plan provided did not address the sounding of the alarm in the event of a lockdown.
2. The emergency preparedness plan provided did not address plans for the continuity of operations in the event of a disaster.
3. Staff 1 acknowledged the missing alarm for lockdown and that the plans for the continuity of operations were not in writing in the plan.
Evidence:
1. The emergency preparedness plan provided did not address the sounding of the alarm in the event of a lockdown.
2. The emergency preparedness plan provided did not address plans for the continuity of operations in the event of a disaster.
3. Staff 1 acknowledged the missing alarm for lockdown and that the plans for the continuity of operations were not in writing in the plan.
Plan of Correction: The facility responded with the following:
The emergency preparedness plan will be re-written to ensure that all required components are addressed in writing in the plan. The provided model form will be used as a guide.
The emergency preparedness plan will be re-written to ensure that all required components are addressed in writing in the plan. The provided model form will be used as a guide.