Inspection · 2022-07-08
Date
2022-07-08
Complaint Related
Yes
Licensing Inspector
Lynette A Storr
(703) 309-9153
(703) 309-9153
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 Staffing and Supervision.
8VAC20-820 THE LICENSE.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced investigation was conducted on 7/8/2022, and follow-up interviews were conducted on 7/12/2022 and 7/26/2022 in response to a complaint that was received by the licensing office on 6/14/2022 regarding staff qualifications. There were 148 children (infant-5yrs) directly supervised by 36 staff on the day of the inspection. Based on staff interviews and records reviewed the preponderance of evidence gathered during the investigation support the allegations. The complaint is determined to be valid, violations were identified on the Violation Notice. If you have any questions regarding this inspection, please contact the Licensing Inspector, Maria Soto at maria.soto@doe.virginia.gov or (571) 835-5058.
Violations
9Standard 22.1-289.035-A
Based on record review and interview, the center failed to obtain a repeat background check for an employee, every five years as required.
Evidence:
Staff #2's record contains a central registry check that was last updated on 6/28/2017.
Evidence:
Staff #2's record contains a central registry check that was last updated on 6/28/2017.
Plan of Correction: Staff #2's updated central registry check will be submitted no later than 9/2/2022.
The board has directed an audit to confirm that all other central registry checks have been updated as required, even for administrative employees with non-childcare responsibilities.
The board has directed an audit to confirm that all other central registry checks have been updated as required, even for administrative employees with non-childcare responsibilities.
Standard 22.1-289.035-B-2
Based on record review, the center failed to obtain fingerprint results for a staff member.
Evidence:
Staff #2 and Staff #3 stated that fingerprint results were not obtained for Staff #4. Staff #2 confirmed that Staff #4 has been receiving a W2 statement at the end of the year and they have been on the center's payroll since 2018.
Evidence:
Staff #2 and Staff #3 stated that fingerprint results were not obtained for Staff #4. Staff #2 confirmed that Staff #4 has been receiving a W2 statement at the end of the year and they have been on the center's payroll since 2018.
Plan of Correction: An appointment will be set with Staff #4 no later than September 30. If it is determined that Staff #4 will continue to provide services as an employee, then all necessary paperwork will be completed at the conclusion of the meeting. As results of the paperwork are returned to the center, the center will inform the licensing specialist. if it is determined that Staff #4 will provide services as a contractor who will receive a 1099, then every effort will be made to have Staff #4 provide services when children are not in the building. When his services are needed when children are in the building, then he will be accompanied by a member of the administrative team or their designee.
Standard 8VAC20-770-40-B
Based on interviews and record review, the center failed to ensure that no person with a disqualifying background who has not been granted a waiver according to 8VAC20-770-90 may operate or volunteer or work at a facility governed by this chapter.
Evidence:
1. Staff #1's record contains disqualifying fingerprint results that indicate that the staff member is not eligible to work at the facility.
2. The center obtained the disqualifying background check on 10/10/2018.
3. Payroll record and interviews conducted provided evidence that Staff #1 is an employee now and has been an employee since 2018.
Evidence:
1. Staff #1's record contains disqualifying fingerprint results that indicate that the staff member is not eligible to work at the facility.
2. The center obtained the disqualifying background check on 10/10/2018.
3. Payroll record and interviews conducted provided evidence that Staff #1 is an employee now and has been an employee since 2018.
Plan of Correction: Upon learning of Staff #1's potentially disqualifying offense, the center Board placed Staff #1 on administrative leave in February 2022 for inquiry into Staff #1's eligibility for employment. Upon confirmation from VDOE that Staff #1 is disqualified from employment, Staff #1 has been separated from employment. (8/24/2022 Staff #1 employment concludes)
The Board has directed a review of background check files and confirmed that no other employee is ineligible to work for the facility.
(8/31/2022 review of all background check files completed)
The Board has directed a review of background check files and confirmed that no other employee is ineligible to work for the facility.
(8/31/2022 review of all background check files completed)
Standard 8VAC20-770-60-B
Based on record review and interview, the center failed to obtain a completed sworn statement or affirmation.
Evidence:
Staff #2 and Staff #3 stated that Staff #4 has not completed a sworn statement or affirmation form, required prior to employment. Staff #2 confirmed that Staff #4 has been receiving a W2 statement at the end of the year and they have been on the center's payroll since 2018.
Evidence:
Staff #2 and Staff #3 stated that Staff #4 has not completed a sworn statement or affirmation form, required prior to employment. Staff #2 confirmed that Staff #4 has been receiving a W2 statement at the end of the year and they have been on the center's payroll since 2018.
Plan of Correction: Same as response for 22.1-(14.1)-289.035-B-2 above. In addition, the Board will draft a policy to guide staff in determining when independent contractors or others who infrequently visit the center in non-childcare roles should be required to provide fingerprints, provide sworn statements or affirmations and a registry check obtained.
Standard 8VAC20-770-60-C-2
Based on record review and interview, the center failed to obtain a central registry finding within 30 days of employment for a staff member.
Evidence:
Staff #2 and Staff #3 stated that a central registry check was not obtained for Staff #4. Staff #2 confirmed that Staff #4 has been receiving a W2 statement at the end of the year and they have been on the center's payroll since 2018.
Evidence:
Staff #2 and Staff #3 stated that a central registry check was not obtained for Staff #4. Staff #2 confirmed that Staff #4 has been receiving a W2 statement at the end of the year and they have been on the center's payroll since 2018.
Plan of Correction: Same as response for 22.1-(14.1)-289.035-B-2 and 8VAC20-770-(BC)-60-B, both above.
Standard 8VAC20-770-70-A
Based on record review and interview, background check records were not kept at the location where the person is an employee.
Evidence:
Staff #1's file was not available for review during the inspection.
Evidence:
Staff #1's file was not available for review during the inspection.
Plan of Correction: When Staff #1 was placed on administrative leave since February 2022, the Board obtained Staff #1's records as part of its inquiry into Staff #1's employment and eligibility. The Board has directed a review to ensure that all other employees files remain onsite.
Standard 8VAC20-780-160-C
Based on record review the center did not ensure that all staff members submitted the results of a follow-up tuberculosis (TB) screening/test at least every two years form the date of the last TB screening/test.
Evidence:
Staff #1's record contains a TB screening/test that was last updated on 4/5/2018.
Evidence:
Staff #1's record contains a TB screening/test that was last updated on 4/5/2018.
Plan of Correction: Staff #1, who has been on administrative leave since February 2022, has been separated from employment. The Board has directed a review of all other employee files to ensure that TB screening/tests are updated and will complete such review by 09/15/2022.
Standard 8VAC20-780-180-A
Based on interviews and record review, the center did not ensure staff demonstrated good character and reputation when staff provided inaccurate information during an investigation.
Evidence:
1. Staff #3 stated on 7/8/2022 that Staff #1 was not an employee, that they did not have a file on Staff #1 because "they were working at the facility as a contractor" and, Staff #3 denied that Staff #1 had a disqualifying background check.
2. Board Officer #1 confirmed that Staff #1 is an employee of the center and that Staff #1 has a file.
3. Staff #1's record contains a disqualifying background check dated 10/10/2018.
4. Staff #2 confirmed on 7/12/2022 that Staff #1 receives a W2 form at the end of the year and that they work 40 hours per week. Staff #2 also confirmed that Staff #1 received a paycheck on 7/22/2022 and that they have been on the center's payroll since 2018.
5. The confirmation statements made by Board Officer #1 and Staff #2 provide evidence that Staff #1 is an employee now and has been an employee since 2018.
6. The confirmation statements made by Board Officer #1 and Staff #2 do not support the statement made by Staff #3 to the Department's representative. The facts and evidence support that Staff #3 did not provide accurate information regarding the employment status and background results of Staff #1 to the Department's representative.
Evidence:
1. Staff #3 stated on 7/8/2022 that Staff #1 was not an employee, that they did not have a file on Staff #1 because "they were working at the facility as a contractor" and, Staff #3 denied that Staff #1 had a disqualifying background check.
2. Board Officer #1 confirmed that Staff #1 is an employee of the center and that Staff #1 has a file.
3. Staff #1's record contains a disqualifying background check dated 10/10/2018.
4. Staff #2 confirmed on 7/12/2022 that Staff #1 receives a W2 form at the end of the year and that they work 40 hours per week. Staff #2 also confirmed that Staff #1 received a paycheck on 7/22/2022 and that they have been on the center's payroll since 2018.
5. The confirmation statements made by Board Officer #1 and Staff #2 provide evidence that Staff #1 is an employee now and has been an employee since 2018.
6. The confirmation statements made by Board Officer #1 and Staff #2 do not support the statement made by Staff #3 to the Department's representative. The facts and evidence support that Staff #3 did not provide accurate information regarding the employment status and background results of Staff #1 to the Department's representative.
Plan of Correction: Staff #1 who had been on administrative leave since February 2022, has been separated from employment (8/24/2022)
Staff #3 has been placed on administrative leave while the Board reviews the matter and determines appropriate arrangements for correction and reallocation of responsibility. (8/31/2022)
The Board will engage external counsel to provide training to the center's obligations for employment screening and cooperation with VDOE. That training shall be completed no later than October 15, 2022.
Staff #3 has been placed on administrative leave while the Board reviews the matter and determines appropriate arrangements for correction and reallocation of responsibility. (8/31/2022)
The Board will engage external counsel to provide training to the center's obligations for employment screening and cooperation with VDOE. That training shall be completed no later than October 15, 2022.
Standard 8VAC20-780-340-A
Based on record review and interviews, the center failed to ensure children's care, protection and guidance.
Evidence:
Staff #3, responsible for overseeing all activities of staff and ensuring the supervision of children, failed to ensure care, protection and guidance to the children attending the center when Staff #3 allowed an individual with disqualifying background check results to work around children at the licensed child day center since 2018. (Disqualifying background check results were dated 10/10/2018).
Evidence:
Staff #3, responsible for overseeing all activities of staff and ensuring the supervision of children, failed to ensure care, protection and guidance to the children attending the center when Staff #3 allowed an individual with disqualifying background check results to work around children at the licensed child day center since 2018. (Disqualifying background check results were dated 10/10/2018).
Plan of Correction: Staff #3 has been placed on administrative leave while the Board reviews the matter and determines appropriate arrangements for correction and reallocation of responsibilities (8/31/2022)