Inspection · 2022-12-09
Date
2022-12-09
Complaint Related
No
Licensing Inspector
Krysten Hunt
(804) 335-6724
(804) 335-6724
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.
? 20 Access to minor?s records
? 8VAC20-780 Staff Qualifications and Training.
? 22.1 Early Childhood Care and Education
? 8VAC20-780 Physical Plant.
? 8VAC20-780 Staffing and Supervision.
? 8VAC20-780 Programs.
? 8VAC20-780 Special Care Provisions and Emergencies
? 8VAC20-780 Special Services.
? 8VAC20-770 Background Checks
Inspector Notes
An unannounced on-site monitoring inspection was conducted on 12/09/2022. There were 92 children, ages 3 months-6 years, and 20 staff members present during the inspection. The inspector observed the following: arrival, outside play, diapering, morning snack, napping and free choice activities. A total of 5 children?s records and 6 staff records, were reviewed. The inspector discussed the following with staff: CPS check Portal, orientation form on website, and children's record model form.
Kelly Campbell
Licensing Inspector
Office of Child Care Health and Safety
Division of Early Childhood Care and Education
Phone# 540-309-2494
Kelly.campbell@doe.virginia.gov
Violations
12Standard 8VAC20-770-60-B
Based on review of six staff records, the center failed to obtain a completed sworn statement prior to starting the position.
Evidence:
1.Staff # 2 had a hire date of 10/10/2022. A signed sworn statement was not in the record. Staff # 2 was observed working on the day of the inspection.
2.Staff # 6 had a hire date of 8/11/2022. A signed sworn statement was not in the record. Staff # 2 was observed working on the day of the inspection.
Evidence:
1.Staff # 2 had a hire date of 10/10/2022. A signed sworn statement was not in the record. Staff # 2 was observed working on the day of the inspection.
2.Staff # 6 had a hire date of 8/11/2022. A signed sworn statement was not in the record. Staff # 2 was observed working on the day of the inspection.
Plan of Correction: Per the Director : Sworn statements will be completed via paper format, not digitally in Bamboo HR as they had been done before. Sworn statements were completed for the two staff that were missing them.
Standard 8VAC20-770-60-C-2
Based on review of eight staff records, the center failed to obtain the finding from a search of the central registry within 30 days of hire.
Evidence:
1.Staff # 1 had a hire date of 8/11/2022. A return search of the central registry was not in the record. Staff # 7 did not provide documentation when requested.
2.Staff # 4 had a hire date of 8/12/2022. A return search of the central registry was not in the record. Staff # 7 did not provide documentation when requested.
3.Staff # 6 had a hire date of 8/11/2022. A return search of the central registry was not in the record. Staff # 7 did not provide documentation when requested.
Evidence:
1.Staff # 1 had a hire date of 8/11/2022. A return search of the central registry was not in the record. Staff # 7 did not provide documentation when requested.
2.Staff # 4 had a hire date of 8/12/2022. A return search of the central registry was not in the record. Staff # 7 did not provide documentation when requested.
3.Staff # 6 had a hire date of 8/11/2022. A return search of the central registry was not in the record. Staff # 7 did not provide documentation when requested.
Plan of Correction: Per the Director : All Central Registry searches had been mailed, and we showed we had emailed to follow up on their status. However the Office of Background Checks is very delayed. With the searches that have not come back yet, and moving forward, we will be using the portal to access the Child Care Application Processing System and submit the background checks online.
Standard 8VAC20-780-130-A
Based on review of five children?s records, the center failed to ensure that all children had the immunization record prior to beginning attendance.
Evidence:
The record for Child # 2, started on 8/15/2022, did not have the immunization prior to attendance. The immunizations in the record were dated 10/25/2022.
Evidence:
The record for Child # 2, started on 8/15/2022, did not have the immunization prior to attendance. The immunizations in the record were dated 10/25/2022.
Plan of Correction: Per the Director: We will make sure to receive immunization records prior to attendance. We will also make sure to keep all immunization records, and not shred the previous records when receiving new ones.
Standard 8VAC20-780-160-A
Based on interview and review of eight staff records, the center failed to ensure that all staff had a negative tuberculosis (TB) screening at the time of employment, no more than 30 days prior to hire, and before coming in contact with children.
1. Staff # 1 started employment on 8/11/2022 and the date of the TB screening or test was 11/7/2022.
2. Staff # 3 started employment on 12/5/2022 and was working with children on the day of the inspection without a TB screening.
1. Staff # 1 started employment on 8/11/2022 and the date of the TB screening or test was 11/7/2022.
2. Staff # 3 started employment on 12/5/2022 and was working with children on the day of the inspection without a TB screening.
Plan of Correction: Per The Director: The TB test has been completed by the staff member. Moving forward we will ensure to have this documentation completed prior to working with children. We will also be reviewing all staff files to ensure TB tests are up to date
Standard 8VAC20-780-240-B
Based on review of six staff records, the center failed to ensure that staff orientations were completed within seven days of hire.
Evidence:
Staff # 1 was hired on 8/11/2022. Staff # 2 was hired on 10/10/2022. Staff # 4 was hired on 8/12/2022. Staff # 5 was hired on 11/1/2022. Staff # 6 was hired on 8/11/2022. These staff records reviewed lacked documentation that orientation had been completed. Staff # 7 stated that orientation was completed verbally with ever staff by the end of their first day of employment.
Evidence:
Staff # 1 was hired on 8/11/2022. Staff # 2 was hired on 10/10/2022. Staff # 4 was hired on 8/12/2022. Staff # 5 was hired on 11/1/2022. Staff # 6 was hired on 8/11/2022. These staff records reviewed lacked documentation that orientation had been completed. Staff # 7 stated that orientation was completed verbally with ever staff by the end of their first day of employment.
Plan of Correction: Per the Director: While orientation was done verbally, we have since downloaded the VDOE Model Form "Staff Orientation Documentation" and will be using that moving forward to ensure orientation is properly documented.
Standard 8VAC20-780-330-B
Based on observation of the playground area, the center failed to ensure all immediate fall zones had the required amount of resilient surfacing.
Evidence:
Observed on the playground there was a three-bay swing set. The swing set did not have the required resilient surfacing and fall zones required for the equipment. According to the attachment VII in the Standards for Licensed Child Day Center the amount of resilient surfacing and fall zone is determined by double the height of swing set. Based on the height of the swing set the required fall zone that requires resilient surfacing is 12 feet in front of and behind the piece of equipment.
Evidence:
Observed on the playground there was a three-bay swing set. The swing set did not have the required resilient surfacing and fall zones required for the equipment. According to the attachment VII in the Standards for Licensed Child Day Center the amount of resilient surfacing and fall zone is determined by double the height of swing set. Based on the height of the swing set the required fall zone that requires resilient surfacing is 12 feet in front of and behind the piece of equipment.
Plan of Correction: Per the Director: We will be ordering more mulch to ensure that all the fall zones have the correct amount of resilient surfacing. Boarders had also been ordered and were delivered the day after the inspection to help keep the mulch in place.
Standard 8VAC20-780-500-A
Based on observation of toileting, diapering and eating, the center failed to ensure that all staff and children washed hands as required by the standard.
Evidence:
1.Staff # 3 was observed changing a child that had soiled their clothes. The child?s clothes and undergarment were changed. The child finished up and went to start the morning snack process. The child did not wash their hand before getting their plate and sitting at the table and being served morning snack.
2.Staff # 3 was observed changing a child?s soiled clothes and then proceeded to change a diaper of another child. The staff person did not wash their hands between changing the soiled clothing and changing a diaper.
Evidence:
1.Staff # 3 was observed changing a child that had soiled their clothes. The child?s clothes and undergarment were changed. The child finished up and went to start the morning snack process. The child did not wash their hand before getting their plate and sitting at the table and being served morning snack.
2.Staff # 3 was observed changing a child?s soiled clothes and then proceeded to change a diaper of another child. The staff person did not wash their hands between changing the soiled clothing and changing a diaper.
Plan of Correction: Per the Director: We will be reviewing handwashing, toileting, and diapering procedures in the next staff meeting. We also held a one-on-one meeting with the lead guide of the classroom with staff #3 and a plan of improvement was given to them.
Standard 8VAC20-780-500-B
Based on observation of the diapering areas, the center failed to ensure that disposable diapers shall be disposed in a leakproof or plastic-lined storage system that is either foot operated or used in such a way that neither the staff member?s hand not the soiled diaper touches an exterior surface of the storage system during disposal.
Evidence:
1.In all the three infant and toddler rooms, the disposal system had a plastic spring loaded trap door. To dispose of the diaper, either the staff member?s hand or the diaper would have to touch the trap door.
2.In the toddler room, staff # 3 was observed changing clothes of a child that had soiled themselves. The child was underdressed and sat on the changing bench. The changing bench is used for stand up diapering. The children lean over the bench while standing up on the bamboo mat. The changing bench and the bamboo mat that the child stands on during a change/diapering was not cleaned or sanitized after the change. The staff person proceeded to change another diaper. The area was not cleaning or sanitized after the second child was changed. The requirement is for the area to be cleaned and sanitized after each change.
Evidence:
1.In all the three infant and toddler rooms, the disposal system had a plastic spring loaded trap door. To dispose of the diaper, either the staff member?s hand or the diaper would have to touch the trap door.
2.In the toddler room, staff # 3 was observed changing clothes of a child that had soiled themselves. The child was underdressed and sat on the changing bench. The changing bench is used for stand up diapering. The children lean over the bench while standing up on the bamboo mat. The changing bench and the bamboo mat that the child stands on during a change/diapering was not cleaned or sanitized after the change. The staff person proceeded to change another diaper. The area was not cleaning or sanitized after the second child was changed. The requirement is for the area to be cleaned and sanitized after each change.
Plan of Correction: Per the Director: We will be reviewing handwashing, toileting, and diapering procedures in the next staff meeting. The spring loaded trap door from the diaper trash cans were removed during the visit to correct the issue.
Standard 8VAC20-780-520-B
Based on observation, the center failed to ensure that all sunscreens were labeled with the owner?s name.
Evidence:
1.Observed in the toddler room, five sunscreens sitting on the cubbies that were not labeled with the owner?s name.
Evidence:
1.Observed in the toddler room, five sunscreens sitting on the cubbies that were not labeled with the owner?s name.
Plan of Correction: Per the Director: We will be reviewing procedures for handling, storing, and labeling sunscreen with the staff at our next staff meeting.
Standard 8VAC20-780-550-G
Based on record review and interviews, the center failed to ensure that all emergency drills were documented.
Evidence:
The center did not have documentation of a fire evacuation drill for November of 2022. Staff #7 confirmed that a November drill was not conducted.
Evidence:
The center did not have documentation of a fire evacuation drill for November of 2022. Staff #7 confirmed that a November drill was not conducted.
Plan of Correction: Per the Director: Reminders have been added to the school calendar to ensure they are completed each month.
Standard 8VAC20-780-60-A
Based on record review, the center failed to ensure that the separate record for each enrolled child shall contain all the elements as required by the standards.
Evidence:
1. The record for Child # 4 did not include the following information: missing documentation of the first day of attendance, and previous child care or other program.
2. The record for Child #5 did not include the following information: missing documentation of the first day of attendance, the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached (there was not an address or phone number provided for the second designated person) and previous child care and other programs.
Evidence:
1. The record for Child # 4 did not include the following information: missing documentation of the first day of attendance, and previous child care or other program.
2. The record for Child #5 did not include the following information: missing documentation of the first day of attendance, the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached (there was not an address or phone number provided for the second designated person) and previous child care and other programs.
Plan of Correction: Per the Director: We will update our online forms to ensure it has all the required information as listed on the VDOE model "Child Registration" form.
Standard 8VAC20-780-70
Based on review of six staff records, the center failed to ensure that all records were complete per the standard.
Evidence:
1.Staff # 4 had a hire date of 8/12/2022 and did not have the two required reference checks prior to employment.
Evidence:
1.Staff # 4 had a hire date of 8/12/2022 and did not have the two required reference checks prior to employment.
Plan of Correction: Per the Director: We will ensure that reference checks are completed prior to employment.