Inspection · 2024-05-07
Date
2024-05-07
Complaint Related
No
Licensing Inspector
Rebecca Forestier
(540) 309-2835
(540) 309-2835
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.
Yes
Areas Reviewed
8VAC20-790 Introduction
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services
Inspector Notes
An announced subsidy inspection for the religiously exempt child day center was conducted on 05/07/2024. There were a total of 78 children, ages 2 months-5 years, 12 staff providing direct care and supervision, and various support staff present during the inspection. A total of 8 children?s records and 8 staff records, as well as other required documents were reviewed during the inspection. The children were observed participating in learning activities, in free choice play and during lunch. The inspector arrived at 10:10 am and departed at 1:00 pm.
Information gathered during the inspection determined non-compliance with the subsidy program vendor requirements and violations were documented on the violation notice issued to the provider.
Violations
20Standard 8VAC20-790-530-B
Based on document review and staff interviews, the vendor failed to maintain, for each group of children, a written hard copy record of daily attendance that documents the arrival and departure of each child in care as it occurs.
Evidence:
1. The attendance for Classroom 5 had not been taken for 05/07/2024; there were 9 children observed in the group. The attendance record did not document the arrival of each child in care as it occurred.
2. The attendance record for Classroom 6 documented 10 children in care. There were 11 children observed in the group. The attendance record did not document the arrival of each child as is occurred.
3. The attendance record for Classroom 7 documented 8 children in care. There were 11 children observed in the group. The attendance record did not document the arrival of each child as is occurred.
4. The attendance record for each group of children did not document the departure of each child in care as it occurs.
Evidence:
1. The attendance for Classroom 5 had not been taken for 05/07/2024; there were 9 children observed in the group. The attendance record did not document the arrival of each child in care as it occurred.
2. The attendance record for Classroom 6 documented 10 children in care. There were 11 children observed in the group. The attendance record did not document the arrival of each child as is occurred.
3. The attendance record for Classroom 7 documented 8 children in care. There were 11 children observed in the group. The attendance record did not document the arrival of each child as is occurred.
4. The attendance record for each group of children did not document the departure of each child in care as it occurs.
Plan of Correction: New attendance sheets will be made to correct this.
Standard 8VAC20-790-540-B
Based on record review, the vendor failed to ensure that each child?s record contains all of the elements as required by the subsidy program vendor requirements.
Evidence:
1. The record for Child 1 did not contain the following information: the address for each custodial parent?s place of employment (an employer was listed); and the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided).
2. The record for Child 2 did not contain the following information: the address and telephone number for each custodial parent?s place of employment (an employer was listed); and the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided).
3. The record for Child 4 did not contain the following information: the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided).
4. The record for Child 5 did not contain the following information: the telephone number for each custodial parent?s place of employment (an employer was listed).
5. The record for Child 6 did not contain the following information: the home address for each parent who has custody; the telephone number for each custodial parent?s place of employment (an employer was listed); the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided); and a written statement that the vendor will notify the parent when the child become ill and that the parent will arrange to have the child picked up a soon as possible if so requested by the vendor.
6. The record for Child 7 did not contain the following information: the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided); and information on allergies, including food allergies, intolerances to food, medication, or other substances, and actions to be taken in an emergency situation.
7. The record for Child 8 did not contain the following information: the telephone number for each custodial parent?s place of employment (an employer was listed).
Evidence:
1. The record for Child 1 did not contain the following information: the address for each custodial parent?s place of employment (an employer was listed); and the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided).
2. The record for Child 2 did not contain the following information: the address and telephone number for each custodial parent?s place of employment (an employer was listed); and the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided).
3. The record for Child 4 did not contain the following information: the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided).
4. The record for Child 5 did not contain the following information: the telephone number for each custodial parent?s place of employment (an employer was listed).
5. The record for Child 6 did not contain the following information: the home address for each parent who has custody; the telephone number for each custodial parent?s place of employment (an employer was listed); the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided); and a written statement that the vendor will notify the parent when the child become ill and that the parent will arrange to have the child picked up a soon as possible if so requested by the vendor.
6. The record for Child 7 did not contain the following information: the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached (an address was not provided); and information on allergies, including food allergies, intolerances to food, medication, or other substances, and actions to be taken in an emergency situation.
7. The record for Child 8 did not contain the following information: the telephone number for each custodial parent?s place of employment (an employer was listed).
Plan of Correction: The new enrollment forms are to be given to all parents, which contain the required information.
Standard 8VAC20-790-560-A
Based on record review, the vendor failed to ensure that staff shall be evaluated by a health professional and be issued a statement that the individual is determined to be free of communicable tuberculosis. The documentation shall be submitted at the time of employment and prior to coming into contact with children.
Evidence:
1. The record for Staff 1 contained a documented hire date of 02/12/2024. There was not documentation of Staff 1 being determined to be free of communicable tuberculosis in the record for Staff 1.
2. The record for Staff 3 contained a documented hire date of 03/22/2024. There was not documentation of Staff 3 being determined to be free of communicable tuberculosis in the record for Staff 3.
Evidence:
1. The record for Staff 1 contained a documented hire date of 02/12/2024. There was not documentation of Staff 1 being determined to be free of communicable tuberculosis in the record for Staff 1.
2. The record for Staff 3 contained a documented hire date of 03/22/2024. There was not documentation of Staff 3 being determined to be free of communicable tuberculosis in the record for Staff 3.
Plan of Correction: Staff #1 has the earliest appointment at the local health department on 6/10/2024.
Standard 8VAC20-790-600-C
Based on record review, the vendor failed to ensure that orientation training for staff shall be completed prior to the staff member working alone with children and within 7 days of the date of employment.
Evidence:
1. The record for Staff 1 contained a documented hire date of 02/12/2024; there was no documentation that Staff 1 completed staff orientation training. Staff 1 was observed working during the 05/07/2024 inspection.
2. The record for Staff 2 contained a documented hire date of 05/26/2023; there was no documentation that Staff 2 completed staff orientation training. Staff 2 was observed working during the 05/07/2024 inspection.
3. The record for Staff 3 contained a documented hire date of 03/22/2024; there was no documentation that Staff 3 completed staff orientation training. Staff 3 was observed working during the 05/07/2024 inspection.
4. The record for Staff 4 contained a documented hire date of 01/06/2023; there was no documentation that Staff 4 completed staff orientation training. Staff 4 was observed working during the 05/07/2024 inspection.
5. The record for Staff 5 contained a documented hire date of 01/09/2023; there was no documentation that Staff 5 completed staff orientation training. Staff 5 was observed working during the 05/07/2024 inspection.
6. The record for Staff 6 contained a documented hire date of 10/30/2018; there was no documentation that Staff 6 completed staff orientation training. Staff 6 was observed working during the 05/07/2024 inspection.
7. The record for Staff 7 contained a documented hire date of 01/15/2023; there was no documentation that Staff 7 completed staff orientation training. Staff 7 was observed working during the 05/07/2024 inspection.
8. The record for Staff 8 contained a documented hire date of 10/26/2021; there was no documentation that Staff 8 completed staff orientation training. Staff 8 was observed working during the 05/07/2024 inspection.
Evidence:
1. The record for Staff 1 contained a documented hire date of 02/12/2024; there was no documentation that Staff 1 completed staff orientation training. Staff 1 was observed working during the 05/07/2024 inspection.
2. The record for Staff 2 contained a documented hire date of 05/26/2023; there was no documentation that Staff 2 completed staff orientation training. Staff 2 was observed working during the 05/07/2024 inspection.
3. The record for Staff 3 contained a documented hire date of 03/22/2024; there was no documentation that Staff 3 completed staff orientation training. Staff 3 was observed working during the 05/07/2024 inspection.
4. The record for Staff 4 contained a documented hire date of 01/06/2023; there was no documentation that Staff 4 completed staff orientation training. Staff 4 was observed working during the 05/07/2024 inspection.
5. The record for Staff 5 contained a documented hire date of 01/09/2023; there was no documentation that Staff 5 completed staff orientation training. Staff 5 was observed working during the 05/07/2024 inspection.
6. The record for Staff 6 contained a documented hire date of 10/30/2018; there was no documentation that Staff 6 completed staff orientation training. Staff 6 was observed working during the 05/07/2024 inspection.
7. The record for Staff 7 contained a documented hire date of 01/15/2023; there was no documentation that Staff 7 completed staff orientation training. Staff 7 was observed working during the 05/07/2024 inspection.
8. The record for Staff 8 contained a documented hire date of 10/26/2021; there was no documentation that Staff 8 completed staff orientation training. Staff 8 was observed working during the 05/07/2024 inspection.
Plan of Correction: New employee orientation checklist has been made. Staff #8 will train all employees.
Standard 8VAC20-790-600-D-1
Based on document review, the vendor failed to ensure that all staff who work directly with children shall have a current certification in CPR appropriate to the ages of children in care and the training shall include an in-person competency demonstration.
Evidence:
1. The record for Staff 2 contained a documented hire date of 05/26/2023. The current CPR certification obtained by Staff 2 did not require an in-person competency demonstration.
2. The record for Staff 4 contained a documented hire date of 01/06/2023. The current CPR certification obtained by Staff 4 did not require an in-person competency demonstration.
3. The record for Staff 5 contained a documented hire date of 01/09/2023. The current CPR certification obtained by Staff 5 did not require an in-person competency demonstration.
4. The record for Staff 6 contained a documented hire date of 10/30/2018. The current CPR certification obtained by Staff 6 did not require an in-person competency demonstration.
5. The record for Staff 7 contained a documented hire date of 01/15/2023. The current CPR certification obtained by Staff 7 did not require an in-person competency demonstration.
6. The record for Staff 8 contained a documented hire date of 10/26/2023. The current CPR certification obtained by Staff 8 did not require an in-person competency demonstration.
Evidence:
1. The record for Staff 2 contained a documented hire date of 05/26/2023. The current CPR certification obtained by Staff 2 did not require an in-person competency demonstration.
2. The record for Staff 4 contained a documented hire date of 01/06/2023. The current CPR certification obtained by Staff 4 did not require an in-person competency demonstration.
3. The record for Staff 5 contained a documented hire date of 01/09/2023. The current CPR certification obtained by Staff 5 did not require an in-person competency demonstration.
4. The record for Staff 6 contained a documented hire date of 10/30/2018. The current CPR certification obtained by Staff 6 did not require an in-person competency demonstration.
5. The record for Staff 7 contained a documented hire date of 01/15/2023. The current CPR certification obtained by Staff 7 did not require an in-person competency demonstration.
6. The record for Staff 8 contained a documented hire date of 10/26/2023. The current CPR certification obtained by Staff 8 did not require an in-person competency demonstration.
Plan of Correction: Staff #9 is meeting with all staff members on 06/06/2024 to discuss a hands on required CPR class date.
Standard 8VAC20-790-600-F
Based on record review, the vendor failed to ensure that staff who work directly with children shall annually attend at least 16 hours of training and staff development.
Evidence:
1. The record for Staff 4 contained a documented hire date of 01/06/2023; there was no record of annual training hours in the record for Staff 4.
2. The record for Staff 5 contained a documented hire date of 01/19/2023; there was no record of annual training hours in the record for Staff 4.
3. The record for Staff 6 contained a documented hire date of 10/30/2018; there was no record of annual training hours in the record for Staff 6.
4. The record for Staff 7 contained a documented hire date of 01/015/2023; there was no record of annual training hours in the record for Staff 7.
5. The record for Staff 8 contained a documented hire date of 10/26/2021; there was no record of annual training hours in the record for Staff 8.
Evidence:
1. The record for Staff 4 contained a documented hire date of 01/06/2023; there was no record of annual training hours in the record for Staff 4.
2. The record for Staff 5 contained a documented hire date of 01/19/2023; there was no record of annual training hours in the record for Staff 4.
3. The record for Staff 6 contained a documented hire date of 10/30/2018; there was no record of annual training hours in the record for Staff 6.
4. The record for Staff 7 contained a documented hire date of 01/015/2023; there was no record of annual training hours in the record for Staff 7.
5. The record for Staff 8 contained a documented hire date of 10/26/2021; there was no record of annual training hours in the record for Staff 8.
Plan of Correction: Staff #9 is meeting with all staff on 06/06/2024 and notifying them of the 16 hour staff development requirement and they are to begin immediately turning those certifications in for their employment files.
Standard 8VAC20-790-600-I
Based on record review and staff interview, the vendor failed to ensure that there shall be at least one staff on duty who has obtained within the last three years instruction in performing a daily health observation of children.
Evidence: Staff 9 verified that there was not a staff member on duty that has obtained instruction in performing a daily health observation of children within the last three years.
Evidence: Staff 9 verified that there was not a staff member on duty that has obtained instruction in performing a daily health observation of children within the last three years.
Plan of Correction: Staff #8 and #9 will be receiving health assessment training to complete the daily health observation of children.
Standard 8VAC20-790-630-C-2
Based on observation, the vendor failed to ensure that in areas used by children of preschool age or younger electrical outlets shall have protective covers.
Evidence:
1. There were multiple uncovered electrical outlets in Classroom 1.
2. There were multiple uncovered electrical outlets in Classroom 4.
3. There were 4 uncovered electrical outlets in Classroom 6.
4. There were 3 uncovered electrical outlets in Classroom 7.
5. There were 4 uncovered electrical outlets in Classroom 8.
Evidence:
1. There were multiple uncovered electrical outlets in Classroom 1.
2. There were multiple uncovered electrical outlets in Classroom 4.
3. There were 4 uncovered electrical outlets in Classroom 6.
4. There were 3 uncovered electrical outlets in Classroom 7.
5. There were 4 uncovered electrical outlets in Classroom 8.
Plan of Correction: Outlet covers were put in outlets.
Standard 8VAC20-790-640-A
Based on observations, the vendor failed to ensure that hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children.
Evidence:
1. There were various unlocked cleaning materials such as Lysol Wipes and sanitizing sprays on a shelf in Classroom 1.
2. There were various unlocked cleaning materials on a shelf in Classroom 3.
3. There were unlocked cleaning materials on a shelf in Classroom 7.
4. There was an unlocked and open storage closet containing paint and various cleaning materials that was accessible to children.
5. There was an unlocked container of antifreeze on one of the Dodge vans used for daily transportation.
Evidence:
1. There were various unlocked cleaning materials such as Lysol Wipes and sanitizing sprays on a shelf in Classroom 1.
2. There were various unlocked cleaning materials on a shelf in Classroom 3.
3. There were unlocked cleaning materials on a shelf in Classroom 7.
4. There was an unlocked and open storage closet containing paint and various cleaning materials that was accessible to children.
5. There was an unlocked container of antifreeze on one of the Dodge vans used for daily transportation.
Plan of Correction: All cleaning materials are now locked up in either a supply closet of cabinet.
Standard 8VAC20-790-640-C
Based on observations, the vendor failed to ensure that cleaning and sanitizing materials shall be stored separate from food.
Evidence: There was a container of Lysol and a box of cereal stored beside of each other on a shelf in Classroom 7.
Evidence: There was a container of Lysol and a box of cereal stored beside of each other on a shelf in Classroom 7.
Plan of Correction: Cleaning materials have been removed.
Standard 8VAC20-790-670-H
Based on observation and record review, the vendor failed to ensure that children less than 10 years of age shall always be within actual sight and sound supervision of staff.
Evidence:
1. There were 11 children, ages 3 years-4 years, observed in a room without a staff member. Staff 3 was in an adjoining room preparing the children?s food for lunch. The children were not in the actual sight and sound supervision of Staff 3.
2. Child 6 (3 years old) was observed leaving Classroom 7 and going down the hallway to the restroom alone. Child 6 was not in sight and sound supervision of staff from the time that they left the classroom to when they were returned to the classroom by Staff 8.
Evidence:
1. There were 11 children, ages 3 years-4 years, observed in a room without a staff member. Staff 3 was in an adjoining room preparing the children?s food for lunch. The children were not in the actual sight and sound supervision of Staff 3.
2. Child 6 (3 years old) was observed leaving Classroom 7 and going down the hallway to the restroom alone. Child 6 was not in sight and sound supervision of staff from the time that they left the classroom to when they were returned to the classroom by Staff 8.
Plan of Correction: Staff #3 was addressed concerning sight and sound supervision. Staff #3 was written up for this violation.
Standard 8VAC20-790-760-A-1
Based on observations, the vendor failed to ensure that children?s hands shall be washed with soap and running water or disposable wipes before and after eating meals and snacks.
Evidence:
1. The children in Classroom 7 did not wash their hands before eating lunch.
2. The children in Classroom 9 were observed using hand sanitizer before eating lunch; the children did not wash their hands with soap and running water or a disposable wipe before eating.
Evidence:
1. The children in Classroom 7 did not wash their hands before eating lunch.
2. The children in Classroom 9 were observed using hand sanitizer before eating lunch; the children did not wash their hands with soap and running water or a disposable wipe before eating.
Plan of Correction: Staff was addressed as to how to properly wash the children's hands prior to eating.
Standard 8VAC20-790-760-B-3-a
Based on observations, the vendor failed to ensure that the diapering area shall have access to a sink with running warm water.
Evidence: A diaper changing station was observed in Classroom 5; there was not access to a sink in the class. The closest sink was located in the men?s restroom down the hallway from the class.
Evidence: A diaper changing station was observed in Classroom 5; there was not access to a sink in the class. The closest sink was located in the men?s restroom down the hallway from the class.
Plan of Correction: An additional staff member/floater has been placed in the building to relieve the workers to wash hands.
Standard 8VAC20-790-760-C-2
Based on observations, the vendor failed to ensure that toilet chairs shall be emptied promptly and cleaned and sanitized after each use.
Evidence: There were 2 toilet chairs that contained urine in the men?s restroom and 1 toilet chair that contained urine in the women?s restroom. The toilet chairs were not promptly emptied or cleaned and sanitized after each use.
Evidence: There were 2 toilet chairs that contained urine in the men?s restroom and 1 toilet chair that contained urine in the women?s restroom. The toilet chairs were not promptly emptied or cleaned and sanitized after each use.
Plan of Correction: An additional staff member/floater has been added to check toilet chairs hourly and empty, clean and sanitize after being used.
Standard 8VAC20-790-770-D
Based on observations, the vendor failed to ensure that medications shall be kept in a locked place using a safe locking method that prevents access by children.
Evidence: There were 11 individual packets of non-aspirin medication in the unlocked first-aid kit in Classroom 9.
Evidence: There were 11 individual packets of non-aspirin medication in the unlocked first-aid kit in Classroom 9.
Plan of Correction: Packets were removed from facility.
Standard 8VAC20-790-800-A-1
Based on staff interviews, the vendor failed to ensure that the emergency evacuation procedures shall be practiced at least monthly.
Evidence: There was no documentation that emergency evacuation procedures had been practiced; the staff confirmed that the emergency evacuation procedures were not practiced.
Evidence: There was no documentation that emergency evacuation procedures had been practiced; the staff confirmed that the emergency evacuation procedures were not practiced.
Plan of Correction: Safety and security staff have been notified of this requirement and drills will begin in June.
Standard 8VAC20-790-800-A-2
Based on staff interviews, the vendor failed to ensure that the shelter-in-place procedures shall be practiced at least twice a year.
Evidence: There was no documentation that shelter-in-place procedures had been practiced; the staff confirmed that the shelter-in-place procedures were not practiced.
Evidence: There was no documentation that shelter-in-place procedures had been practiced; the staff confirmed that the shelter-in-place procedures were not practiced.
Plan of Correction: Safety and security staff have been notified of this requirement and drills will begin in June.
Standard 8VAC20-790-800-A-3
Based on staff interviews, the vendor failed to ensure that the lockdown procedures shall be practiced at least annually.
Evidence: There was no documentation that lockdown procedures had been practiced; the staff confirmed that the lockdown procedures were not practiced.
Evidence: There was no documentation that lockdown procedures had been practiced; the staff confirmed that the lockdown procedures were not practiced.
Plan of Correction: Safety and security staff have been notified of this requirement and drills will begin in June.
Standard 8VAC20-790-810-C-1
Based on observations, the vendor failed to ensure that when food is brought from home the food container shall be clearly labeled in a way that identifies the owner.
Evidence: There were numerous food items, Velveeta Shells and Cheese, Ramen Noodles, and Chef Boyardee pasta, observed on a shelf in Classroom 1 that were not labeled to identify the owner.
Evidence: There were numerous food items, Velveeta Shells and Cheese, Ramen Noodles, and Chef Boyardee pasta, observed on a shelf in Classroom 1 that were not labeled to identify the owner.
Plan of Correction: All foods are being labeled by staff in classroom 1.
Standard 8VAC20-790-820-B
Based on observations, the vendor failed to ensure that when a child is placed in a highchair the protective belt shall be fastened securely.
Evidence: There was a child in Classroom 4 observed eating a snack in a highchair; the protective belt was not fastened securely.
Evidence: There was a child in Classroom 4 observed eating a snack in a highchair; the protective belt was not fastened securely.
Plan of Correction: Staff has been addressed, and all children placed in a highchair will have a protective belt fastened securely.