Inspection · 2024-03-04
Date
2024-03-04
Complaint Related
No
Licensing Inspector
Brandie Viscayda
(757) 636-3427
(757) 636-3427
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor's records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced renewal inspection was initiated and concluded on 3/4/24 from 11:40am until 5:00pm. At the time of the inspection, there were 77 children in care with 10 staff present. A sample of 8 children's records and 8 staff records were reviewed. Children were observed eating lunch, playing in the gym, engaging in free play and resting quietly during nap time. Handwashing and restroom procedures and parent pick-up procedures were also observed. First aid and emergency supplies, the emergency preparedness plan, documentation of emergency practice drills, medication, children's injury reports and required center postings were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law. Violations were documented on the violation notice issued to the program and discussed with the center director during the exit interview.
Violations
13Standard 22.1-289.035-B-2
Based on record review and interview, the center did not ensure that the results of a national fingerprint search are received for each staff member before employment.
Evidence:
1. The record for staff 1 (date of hire: 12/1/22) contains results of a national fingerprint search dated 12/2/22, which is after her first day of employment.
2. The record for staff 2 (date of hire: 10/24/22) contains results of a national fingerprint search dated 10/25/22, which is after her first day of employment.
3. The record for staff 3 (date of hire: 12/4/23) contains results of a national fingerprint search dated 12/20/23, which is after her first day of employment.
4. The record for staff 4 (date of hire: 11/6/23) contains results of a national fingerprint search dated 11/14/23, which is after her first day of employment.
5. The record for staff 5 (date of hire: 3/1/23) contains results of a national fingerprint search dated 3/13/23, which is after her first day of employment.
6. The center director confirmed that staff 1, staff 2, staff 3, staff 4 and staff 5 began employment at the center prior to receiving the results of their national fingerprint search.
Evidence:
1. The record for staff 1 (date of hire: 12/1/22) contains results of a national fingerprint search dated 12/2/22, which is after her first day of employment.
2. The record for staff 2 (date of hire: 10/24/22) contains results of a national fingerprint search dated 10/25/22, which is after her first day of employment.
3. The record for staff 3 (date of hire: 12/4/23) contains results of a national fingerprint search dated 12/20/23, which is after her first day of employment.
4. The record for staff 4 (date of hire: 11/6/23) contains results of a national fingerprint search dated 11/14/23, which is after her first day of employment.
5. The record for staff 5 (date of hire: 3/1/23) contains results of a national fingerprint search dated 3/13/23, which is after her first day of employment.
6. The center director confirmed that staff 1, staff 2, staff 3, staff 4 and staff 5 began employment at the center prior to receiving the results of their national fingerprint search.
Plan of Correction: The center responded with the following: The school has to make decision of being very short staffed (due to staffing issues everywhere). Therefore being under ratio or hiring as quickly as possible with the understanding that the respective staff member will not be alone with the students until paperwork is completed.
Standard 22.1-289.035-B-4
Based on record review and interview, it was determined that the center did not ensure that a copy of the results of a search of the child abuse and neglect registry is obtained from any state in which the individual has resided in the preceding five years.
Evidence:
1. Staff 6 has a hire date of 1/3/23. Staff 6 indicated on her sworn statement or affirmation that she has resided in the state of North Carolina within the past five years. The results of a search of the child abuse and neglect registry were not available for staff 6 from the states of North Carolina.
2. The center director confirmed that the required out-of-state background checks were not completed for staff 6.
Evidence:
1. Staff 6 has a hire date of 1/3/23. Staff 6 indicated on her sworn statement or affirmation that she has resided in the state of North Carolina within the past five years. The results of a search of the child abuse and neglect registry were not available for staff 6 from the states of North Carolina.
2. The center director confirmed that the required out-of-state background checks were not completed for staff 6.
Plan of Correction: The center responded with the following: NC background check was submitted for staff
member.
member.
Standard 8VAC20-770-60-C-2
Based on record review and interview, the center did not ensure that the results of a central registry finding are received within 30 days of employment.
Evidence:
1. The record for staff 1 (date of hire: 12/1/22) contains a central registry finding result dated 9/26/23, which is more than 30 days after the date of employment.
2. The record for staff 2 (date of hire: 10/24/22) contains a central registry finding result dated 9/26/23, which is more than 30 days after the date of employment.
3. The record for staff 7 (date of hire: 8/22/23) contains a central registry finding result dated 12/9/23, which is more than 30 days after the date of employment.
4. The center director confirmed that the central registry search results for staff 1, staff 2 and staff 7 were received more than 30 days after employment.
Evidence:
1. The record for staff 1 (date of hire: 12/1/22) contains a central registry finding result dated 9/26/23, which is more than 30 days after the date of employment.
2. The record for staff 2 (date of hire: 10/24/22) contains a central registry finding result dated 9/26/23, which is more than 30 days after the date of employment.
3. The record for staff 7 (date of hire: 8/22/23) contains a central registry finding result dated 12/9/23, which is more than 30 days after the date of employment.
4. The center director confirmed that the central registry search results for staff 1, staff 2 and staff 7 were received more than 30 days after employment.
Plan of Correction: The center responded with the following: The school has to make a decision of placing staff without being under ratio. With the understanding that the staff members are not left alone with students until documents are completed.
Standard 8VAC20-780-160-A
Based on record review and interview, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment.
Evidence:
1. The record for staff 1 (date of hire: 12/1/22) contains documentation of a tuberculosis screening dated 2/3/22, which is more than 30 days prior to employment.
2. The record for staff 2 (date of hire: 10/24/22) contains documentation of a tuberculosis screening dated 10/26/22, which is after the date of employment.
3. The record for staff 3 (date of hire: 12/4/23) contains documentation of a tuberculosis screening dated 5/18/23, which is more than 30 days prior to employment.
4. The record for staff 5 (date of hire: 3/1/23) contains documentation of a tuberculosis screening dated 3/22/23, which is after the date of employment.
5. The record for staff 7 (date of hire: 8/22/23) contains documentation of a tuberculosis screening dated 5/17/23, which is more than 30 days prior to employment.
6. The center director confirmed that the tuberculosis screenings for staff 1, staff 2, staff 3, staff 5 and staff 7 were not completed within the required timeframes.
Evidence:
1. The record for staff 1 (date of hire: 12/1/22) contains documentation of a tuberculosis screening dated 2/3/22, which is more than 30 days prior to employment.
2. The record for staff 2 (date of hire: 10/24/22) contains documentation of a tuberculosis screening dated 10/26/22, which is after the date of employment.
3. The record for staff 3 (date of hire: 12/4/23) contains documentation of a tuberculosis screening dated 5/18/23, which is more than 30 days prior to employment.
4. The record for staff 5 (date of hire: 3/1/23) contains documentation of a tuberculosis screening dated 3/22/23, which is after the date of employment.
5. The record for staff 7 (date of hire: 8/22/23) contains documentation of a tuberculosis screening dated 5/17/23, which is more than 30 days prior to employment.
6. The center director confirmed that the tuberculosis screenings for staff 1, staff 2, staff 3, staff 5 and staff 7 were not completed within the required timeframes.
Plan of Correction: The center responded with the following: The school has informed the staff members that their TB Tests needs to be updated by Wednesday, March 13th the latest.
Standard 8VAC20-780-240-A
Based on record review and interview, the center did not ensure that staff complete the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence:
1. The records for staff 2 (date of hire: 10/24/22) and staff 6 (date of hire: 1/3/23) do not contain documentation that they have completed the Virginia Department of Education-sponsored orientation course.
2. The center director confirmed that the records for staff 2 and staff 6 do not contain documentation that the above listed orientation course has been completed.
Evidence:
1. The records for staff 2 (date of hire: 10/24/22) and staff 6 (date of hire: 1/3/23) do not contain documentation that they have completed the Virginia Department of Education-sponsored orientation course.
2. The center director confirmed that the records for staff 2 and staff 6 do not contain documentation that the above listed orientation course has been completed.
Plan of Correction: The center responded with the following: The Campus Director will ensure all documents are in place.
Standard 8VAC20-780-245-A
Based on record review and interview, the center did not ensure that staff shall complete a minimum of 16 hours of training annually appropriate to the age of children in care.
Evidence:
1. The records for staff 1 (date of hire: 12/1/22), staff 2 (date of hire: 10/24/22) and staff 6 (date of hire: 1/3/23) do not contain documentation that they have completed at least 16 hours of annual training.
2. The center director confirmed that the records for staff 1, staff 2, and staff 6 are lacking documentation that they have completed at least 16 hours of annual training.
Evidence:
1. The records for staff 1 (date of hire: 12/1/22), staff 2 (date of hire: 10/24/22) and staff 6 (date of hire: 1/3/23) do not contain documentation that they have completed at least 16 hours of annual training.
2. The center director confirmed that the records for staff 1, staff 2, and staff 6 are lacking documentation that they have completed at least 16 hours of annual training.
Plan of Correction: The center responded with the following: The school year is still in session and the 16 hours of training is done August-August. Every month the staff members take training which will be documented in the future.
Standard 8VAC20-780-340-F
Based on observation, the center did not ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff.
Evidence:
During the inspection, licensing inspectors observed staff 8 walking out of a classroom across the hall from the pre-k/kindergarten classroom, which is the classroom staff 8 was assigned to supervise. The pre-k/kindergarten classroom had 19 children who were napping during this time. There was no other staff person in the pre-k/kindergarten classroom during the time that staff 8 was out of the room, leaving the children out of actual sight and sound supervision of staff for an undetermined amount of time.
Evidence:
During the inspection, licensing inspectors observed staff 8 walking out of a classroom across the hall from the pre-k/kindergarten classroom, which is the classroom staff 8 was assigned to supervise. The pre-k/kindergarten classroom had 19 children who were napping during this time. There was no other staff person in the pre-k/kindergarten classroom during the time that staff 8 was out of the room, leaving the children out of actual sight and sound supervision of staff for an undetermined amount of time.
Plan of Correction: The center responded with the following: We spoke to staff 8 about stepping out of the classroom. She had a student arrive late and she was putting the students bag in their cubby in front of the viewing window. She noticed the classroom in front of hers was not spaced correctly for nap. She told the teacher the nap mats needed to be 12 inches apart and then she went back to class. As she is the leader for that school she felt it was her responsibility to let the teacher be aware. We spoke to all of the staff about addressing any concerns after school hours.
Standard 8VAC20-780-510-I
Based on medication review and interview, the center did not ensure that they only administer prescription medication to a child that is maintained in the original container.
Evidence:
1. There is an emergency medication for child 1 being stored at the center that is not in the original container. The medication has been administered to child 1 while in care.
2. The center director confirmed that the medication administered to child 1 is not being stored in it's original container.
Evidence:
1. There is an emergency medication for child 1 being stored at the center that is not in the original container. The medication has been administered to child 1 while in care.
2. The center director confirmed that the medication administered to child 1 is not being stored in it's original container.
Plan of Correction: The center responded with the following: The school will ensure parents send in the medication in the original container.
Standard 8VAC20-780-550-D
Based on a review of the practice emergency drill log and interview, the center did not ensure that a monthly practice evacuation drill is implemented.
Evidence:
1. There is no practice evacuation drill documented on the center's drill log for the month of August 2023.
2. The center director confirmed that a practice evacuation drill was not conducted for the month of August 2023.
Evidence:
1. There is no practice evacuation drill documented on the center's drill log for the month of August 2023.
2. The center director confirmed that a practice evacuation drill was not conducted for the month of August 2023.
Plan of Correction: The center responded with the following: The school will conduct Fire Drills in the summer months. In August the school is open only for 2 weeks of camp.
Standard 8VAC20-780-550-G
Based on a review of the emergency drill log and interview, the center did not ensure that documentation of emergency practice drills contain all the required elements.
Evidence:
1. The emergency drill log for the center does not include the time of the drill, the method used for notification of the drill, any special conditions simulated or problems encountered, if any.
2. The center director confirmed that the center's emergency drill log does not contain the above required elements.
Evidence:
1. The emergency drill log for the center does not include the time of the drill, the method used for notification of the drill, any special conditions simulated or problems encountered, if any.
2. The center director confirmed that the center's emergency drill log does not contain the above required elements.
Plan of Correction: The center responded with the following: The school will ensure the Campus Director has the correct form when logging all emergency responses. The updated forms were emailed to the campus.
Standard 8VAC20-780-550-P
Based on a review of children's injury reports, the center did not ensure that a written record of children's serious and minor injuries include all of the required information.
Evidence:
1. Ten out of ten children's injury reports reviewed were missing the time the injury occurred; three out of ten were missing the date and time when parents were notified; four out of ten were missing staff and parent signatures or two staff signatures; and, three out of ten were missing documentation of how the parent was notified.
2. The center director confirmed that the children's injury reports do not contain all the required information.
Evidence:
1. Ten out of ten children's injury reports reviewed were missing the time the injury occurred; three out of ten were missing the date and time when parents were notified; four out of ten were missing staff and parent signatures or two staff signatures; and, three out of ten were missing documentation of how the parent was notified.
2. The center director confirmed that the children's injury reports do not contain all the required information.
Plan of Correction: The center responded with the following: The Campus Director mistakenly had printed the outdated Injury Report Forms. The updated document will be used moving forward.
Standard 8VAC20-780-560-G
Based on observation, the center did not ensure that food brought from home is dated and labeled in a way that identifies the owner.
Evidence:
Out of 21 lunchboxes observed during the inspection, there were 14 that were not dated and 2 that were not dated or labeled with the child's name.
Evidence:
Out of 21 lunchboxes observed during the inspection, there were 14 that were not dated and 2 that were not dated or labeled with the child's name.
Plan of Correction: The center responded with the following: The school will make sure all parents have labeled lunchboxes and dated as well.
Standard 8VAC20-780-70
Based on record review and interview, the center did not ensure that staff records contain all the required information.
Evidence:
1. Staff 1 (date of hire: 12/1/22) has a documented job position of assistant. The center director stated staff 1 was promoted from assistant to program leader in February 2023. Staff 1's record does not contain documentation that she possesses the experience or the 24 hours of training required for the job position of program leader. Staff 1's record also does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
2. The record for staff 2 (date of hire: 10/24/22) does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
3. The record for staff 3 (date of hire: 12/4/23) does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
4. Staff 4 (date of hire: 11/6/23) has a documented job position of program leader. The record for staff 4 does not contain documentation to demonstrate that she possesses the experience required by the job position of program leader. Staff 4's record also does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
5. Staff 5 (date of hire: 3/1/23) has a documented job position of program director. The record for staff 5 does not contain documentation that she possess the experience required by the job position of program director. Staff 5's record also contains documentation that only one reference as to character and reputation as well as competency were checked before employment, where two are required.
6. Staff 7 (date of hire: 8/22/23) has a documented job position of program leader. The record for staff 7 does not contain documentation to demonstrate that she possesses the education required by the job position of program leader.
7. The center director confirmed that the records for staff 1, staff 2, staff 3, staff 4, staff 5 and staff 7 are lacking documentation of the above listed items.
Evidence:
1. Staff 1 (date of hire: 12/1/22) has a documented job position of assistant. The center director stated staff 1 was promoted from assistant to program leader in February 2023. Staff 1's record does not contain documentation that she possesses the experience or the 24 hours of training required for the job position of program leader. Staff 1's record also does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
2. The record for staff 2 (date of hire: 10/24/22) does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
3. The record for staff 3 (date of hire: 12/4/23) does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
4. Staff 4 (date of hire: 11/6/23) has a documented job position of program leader. The record for staff 4 does not contain documentation to demonstrate that she possesses the experience required by the job position of program leader. Staff 4's record also does not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
5. Staff 5 (date of hire: 3/1/23) has a documented job position of program director. The record for staff 5 does not contain documentation that she possess the experience required by the job position of program director. Staff 5's record also contains documentation that only one reference as to character and reputation as well as competency were checked before employment, where two are required.
6. Staff 7 (date of hire: 8/22/23) has a documented job position of program leader. The record for staff 7 does not contain documentation to demonstrate that she possesses the education required by the job position of program leader.
7. The center director confirmed that the records for staff 1, staff 2, staff 3, staff 4, staff 5 and staff 7 are lacking documentation of the above listed items.
Plan of Correction: The center responded with the following: The staff member has worked in Public Schools for many years prior to coming to work for MAV. After working with the school for one year the staff member was switched to Toddler care. The school will ensure that the staff member has a Program Leader form filled out.
The Campus Director has required the staff members to submit the required reference letters by Wednesday, March 13th.
The Campus Director has required the staff members to submit the required reference letters by Wednesday, March 13th.