Inspection · 2024-04-22
Date
2024-04-22
Complaint Related
No
Licensing Inspector
Beth Velke
(804) 629-8302
(804) 629-8302
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
32.1 Report by person other than physician
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted on 4/22/24 from 7:45 a.m. to 10:40 a.m. with the Director. There were 87 children in care, ranging in age from 11 months to five-years-old, supervised by 19 staff. The children were observed in group time and reading books. Five child records and seven staff records were reviewed. Ten medications and authorization forms were reviewed. Required postings were observed. The attendance, menu, first aid kit and emergency drill log were also reviewed. The most recent Fire Inspection on file was dated 3/19/24 and the most recent Health Inspection on file was dated 8/19/23. Areas of non-compliance are identified in the Violation Notice. If you have questions regarding this inspection, please contact the Licensing Inspector, Beth Velke, at beth.velke@doe.virginia.gov or 804-629-8302.
Please complete the "Plan of Correction" and "Date to be Corrected" areas on the Violation Notice for each violation cited and return to me by 5 p.m. on 5/15/24.
Violations
12Standard 22.1-289.035-B-2
Based on review of six staff records, the program did not obtain the results of a national fingerprint-based criminal history record check for one staff prior to employment.
Evidence: The record for Staff #5, with a start date of 4/8/24, did not contain documentation of the results of a national fingerprint background check at the time of inspection.
Evidence: The record for Staff #5, with a start date of 4/8/24, did not contain documentation of the results of a national fingerprint background check at the time of inspection.
Plan of Correction: All fingerprint results will be received prior to any staff member beginning employment.
Standard 8VAC20-770-60-C-2
Based on review six staff records; the center did not obtain documentation of the results of a central registry search within 30 days of employment for all staff members.
Evidence: The record for Staff #4 with a start date of 2/1/24, the results of the Central registry search background check was dated 3/20/24.
Evidence: The record for Staff #4 with a start date of 2/1/24, the results of the Central registry search background check was dated 3/20/24.
Plan of Correction: Moving forward, if the results of the Central Registry Search are not received within three weeks after mailing, a call will be placed to check on the status.
Standard 8VAC20-780-160-A
Based on a review of six staff files, the center did not obtain documentation of a tuberculosis (TB) screening for staff at the time of employment and prior to coming in contact with children.
Evidence:
1. The record for Staff #4, with an employment date of 2/1/24, contained documentation of a tuberculosis screening dated 2/12/24.
2. The record for Staff #5, with an employment date of 4/8/24, did not contain documentation of a negative tuberculosis screening.
Evidence:
1. The record for Staff #4, with an employment date of 2/1/24, contained documentation of a tuberculosis screening dated 2/12/24.
2. The record for Staff #5, with an employment date of 4/8/24, did not contain documentation of a negative tuberculosis screening.
Plan of Correction: Ensure all staff has a TB screening within 30 days of start date and that all TB screens are repeated every two years on time.
Standard 8VAC20-780-270-A
Repeat Violation Based on observation, it was determined that not all areas inside the center were maintained in a safe and operable condition.
Evidence:
1. In the infant room, a foam mat near the outside door was curling, posing a trip hazard.
2. Chipping paint was observed in the infant room near the highchairs, in the Bumblebees class, near the home living area, and in the Dragonflies room on the windowsill.
3. In the Dolphins room, four screws that extended approximately 15 thread lengths were observed at the base of the toilets, and in the Pandas room, two screws that extended approximately 20 thread lengths were observed at the base of the toilets, creating an impalement and scratch hazard.
Evidence:
1. In the infant room, a foam mat near the outside door was curling, posing a trip hazard.
2. Chipping paint was observed in the infant room near the highchairs, in the Bumblebees class, near the home living area, and in the Dragonflies room on the windowsill.
3. In the Dolphins room, four screws that extended approximately 15 thread lengths were observed at the base of the toilets, and in the Pandas room, two screws that extended approximately 20 thread lengths were observed at the base of the toilets, creating an impalement and scratch hazard.
Plan of Correction: The mat in the infant room has been removed and a new mat is in place.
The paint in all three areas will be corrected so that no paint chipping is visible.
The screws at the base of the toilets will be trimmed to a length of no more than eight threads being exposed.
The paint in all three areas will be corrected so that no paint chipping is visible.
The screws at the base of the toilets will be trimmed to a length of no more than eight threads being exposed.
Standard 8VAC20-780-290-A-3
Based on observation, the facility did not ensure that electrical outlets had protective covers.
Evidence: In the Dolphins room, a power strip (surge protector) was observed, with two outlets that were not covered and in the Flamingos room, a power strip was observed with three outlets that were not covered.
Evidence: In the Dolphins room, a power strip (surge protector) was observed, with two outlets that were not covered and in the Flamingos room, a power strip was observed with three outlets that were not covered.
Plan of Correction: All unused outlets will have appropriate covers placed in them at all times.
Standard 8VAC20-780-440-B
Based on observation and staff interviews; it was determined that the center did not always ensure that cribs were identified for use by a specific child.
Evidence: In the infant room, four cribs were not labeled with the name of the specific child it was assigned to.
Evidence: In the infant room, four cribs were not labeled with the name of the specific child it was assigned to.
Plan of Correction: The names have been re-written and protected by clear tape so they do not rub off. This will be the regular practice moving forward.
Standard 8VAC20-780-450-E
Based on observation, it was determined the center did not ensure that when mattresses are used, they will be covered with a waterproof material which can be cleaned and sanitized.
Evidence: In the infant room, two mattresses were observed with cracks and tears causing them to no longer be waterproof material which can be cleaned and sanitized.
Evidence: In the infant room, two mattresses were observed with cracks and tears causing them to no longer be waterproof material which can be cleaned and sanitized.
Plan of Correction: All mattresses were inspected for cracks and tears. Those with cracks or tears are not in use and will be replaced before needed.
Standard 8VAC20-780-500-B
Based on observation, it was determined that not all procedures for diapering were followed.
Evidence: In the Bumblebees room, a ball was observed on top of the diapering surface.
Evidence: In the Bumblebees room, a ball was observed on top of the diapering surface.
Plan of Correction: In the event a ball is tossed, or any other item is on the diapering changing pad, the item will be removed and sanitized before being available for use.
Standard 8VAC20-780-510-E
Based on review of medication it was determined that the center did not follow procedures regarding expired medication.
Evidence: The emergency medication on site for Child #6 and Child #7 expired on 3/24.
Evidence: The emergency medication on site for Child #6 and Child #7 expired on 3/24.
Plan of Correction: When the emergency medication lockbox is reviewed each month, special attention will be given to ensure that all medications are replaced prior to their expiration,
Standard 8VAC20-780-520-C
Based on review of authorizations for diaper ointment/cream, parent authorizations had expired.
Evidence: Parent authorizations for Child #6, expired on 3/2/24 and Child #7, expired on 4/13/24.
Evidence: Parent authorizations for Child #6, expired on 3/2/24 and Child #7, expired on 4/13/24.
Plan of Correction: Authorization dates were reviewed and new forms have been signed by parents.
Standard 8VAC20-780-570-E
Based on observation, the center did not ensure that infant bottles were dated and labeled with the child?s name.
Evidence: In the infant room, there were two bottles observed in the refrigerator that were not labeled with the date or a child?s name.
Evidence: In the infant room, there were two bottles observed in the refrigerator that were not labeled with the date or a child?s name.
Plan of Correction: Discussion with parents were had to remind of the importance of brining all items pre-labeled with child's name and date. Anything unlabeled is corrected by infant room staff right away.
Standard 8VAC20-780-80-A
Repeat Violation
Based on review of the written attendance record, the center did not ensure they maintained a written record of daily attendance for each group of children documenting arrival and departure of each child in care as it occurs.
Evidence: In the infant classroom, there was no written record of attendance.
Based on review of the written attendance record, the center did not ensure they maintained a written record of daily attendance for each group of children documenting arrival and departure of each child in care as it occurs.
Evidence: In the infant classroom, there was no written record of attendance.
Plan of Correction: Staff has been re-trained on the importance and expectation of checking each child in on the written attendance form upon arrival and not just in the electronic version of attendance.