Inspection · 2023-04-25
Date
2023-04-25
Complaint Related
No
Licensing Inspector
Florence Martus
(804) 389-0157
(804) 389-0157
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
22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
32.1 Report by person other than physician
54.1 Must be MAT Certified.
63.2 Child abuse and neglect
Inspector Notes
A code compliance inspection was conducted on Tuesday, April 25, 2023. The inspector was on site from 9:45am to approximately 11:10am. There were 25 children in attendance with 6 staff directly supervising. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility including classrooms, hallways, the outdoor play area, and bathrooms were inspected. Five children's records and six 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.
Violations
5Standard 22.1-289.031-B-4
Based on a review of five children's records, the center did not ensure that two children in the center were in compliance with the of 32.1-46 regarding the immunization of children against certain diseases.
Evidence: The center had not verified that the immunizations for Child #1, enrolled 09/06/22, and for Child #3, enrolled 09/06/22, were in compliance.
Evidence: The center had not verified that the immunizations for Child #1, enrolled 09/06/22, and for Child #3, enrolled 09/06/22, were in compliance.
Plan of Correction: Director will email parents to request the missing immunizations.
Standard 22.1-289.031-B-6
Based on a review of six staff records, the center did not establish and implement a procedure to ensure that all staff are able to recognize the signs of child abuse and neglect.
Evidence: The records of Staff #3, Staff #4, and Staff #5 did not contain documentation that the staff have received training to be able to recognize the signs of child abuse and neglect.
Evidence: The records of Staff #3, Staff #4, and Staff #5 did not contain documentation that the staff have received training to be able to recognize the signs of child abuse and neglect.
Plan of Correction: Director will set up a date for all staff to complete the child abuse and neglect training to ensure all staff members have completed the training.
Standard 22.1-289.035-A
Based on a review of six staff records and interview, the center did not ensure one staff completed a required background check every five years.
Evidence: 1) The record of Staff #4, employed 02/14/18, contained documentation of a fingerprint-based national criminal background check dated 02/14/2018. The repeat background check should have been obtained prior to 02/14/2023.
2) During interview, a member of management acknowledged the fingerprints were not completed every five years as required.
Evidence: 1) The record of Staff #4, employed 02/14/18, contained documentation of a fingerprint-based national criminal background check dated 02/14/2018. The repeat background check should have been obtained prior to 02/14/2023.
2) During interview, a member of management acknowledged the fingerprints were not completed every five years as required.
Plan of Correction: The fingerprints will be requested as soon as possible. All staff due to repeat will complete before expiration.
Standard 22.1-289.035-B-2
Based on a review of six staff records and interview, the center did not ensure two staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment.
Evidence: 1) The results of the fingerprint-based national criminal background check in the record of Staff #3, employed 08/15/22, were dated 10/21/22.
2) The results of the fingerprint-based national criminal background check in the record of Staff #5, employed 09/06/21, were dated 10/04/21.
3) During interview, management confirmed the fingerprint-based national criminal background check for Staff #3 and Staff #5 were not obtained prior to employment.
Evidence: 1) The results of the fingerprint-based national criminal background check in the record of Staff #3, employed 08/15/22, were dated 10/21/22.
2) The results of the fingerprint-based national criminal background check in the record of Staff #5, employed 09/06/21, were dated 10/04/21.
3) During interview, management confirmed the fingerprint-based national criminal background check for Staff #3 and Staff #5 were not obtained prior to employment.
Plan of Correction: Corrected. In the future, the center will utilize a checklist to ensure all required documentation is on file for each new staff member.
Standard 8VAC20-770-40-D-2
Based on a review of six staff records and interview, the center did not ensure four staff had two required background checks within the required timeframes.
Evidence: 1) The record of Staff #1, employed 08/15/22, did not contain the results of the
central registry check.
2) The record of Staff #3, employed 08/15/22, did not contain the results of the central registry check or a complete sworn statement or affirmation.
3) The record of Staff #4, employed 02/14/18, did not contain the results of the central registry check or a complete sworn statement or affirmation.
4) The results of the central registry check in the record of Staff #5, employed 09/06/21, were dated 11/10/21. The sworn statement was completed on 09/26/21.
A complete sworn statement or affirmation is required before employment. A search of the central registry check is required within 30 days of employment.
Evidence: 1) The record of Staff #1, employed 08/15/22, did not contain the results of the
central registry check.
2) The record of Staff #3, employed 08/15/22, did not contain the results of the central registry check or a complete sworn statement or affirmation.
3) The record of Staff #4, employed 02/14/18, did not contain the results of the central registry check or a complete sworn statement or affirmation.
4) The results of the central registry check in the record of Staff #5, employed 09/06/21, were dated 11/10/21. The sworn statement was completed on 09/26/21.
A complete sworn statement or affirmation is required before employment. A search of the central registry check is required within 30 days of employment.
Plan of Correction: The missing sworn statements were signed on 04/27/23. The center requested the missing central registry checks for Staff #1, Staff #3, and Staff #4.