Inspection · 2024-08-01
Date
2024-08-01
Complaint Related
No
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 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.
8VAC20-770 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, on-site monitoring inspection occurred on 8/1/2024, as a part of the licensure period. The on-site inspection began at 10:20am and ended at 1:23pm. The inspector reviewed compliance in the areas listed above. There were 118 children present and 24 staff. The inspector reviewed 10 children?s records and 2 staff records on-site on 8/1/2024. This inspection included document review of policies and procedures, medication authorization forms, a tour of the facility, interviews and observations. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 8/8/2024. A POC submitted after this date will not appear on the public website.
Violations
11Standard 8VAC20-780-130-A
REPEAT VIOLATION
Based on record review and interview, the center did not obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence: No documentation of immunizations in Child #10's record. Director stated child has been attending the center for several years.
Based on record review and interview, the center did not obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence: No documentation of immunizations in Child #10's record. Director stated child has been attending the center for several years.
Plan of Correction: Parents of child #10 have been contacted requesting required
documentation of immunizations be submitted before the last day of the 2023-
2024 care and early learning year, 27 August 2024.
documentation of immunizations be submitted before the last day of the 2023-
2024 care and early learning year, 27 August 2024.
Standard 8VAC20-780-130-E
Based on record review and interview, the center did not obtain documentation of additional immunizations once every six months for children under the age of two years.
Evidence: Child #4's date of most recent immunizations 12/2023. Child #4 is 14 months old.
Child #6 most recent date of immunizations 7/2023. Child #6 is 24 months old.
Evidence: Child #4's date of most recent immunizations 12/2023. Child #4 is 14 months old.
Child #6 most recent date of immunizations 7/2023. Child #6 is 24 months old.
Plan of Correction: Parents of child #4 and #6 have been contacted and requested to provide the required documents/documentation at their most immediate
convenience and before the last day of the current care and early learning year, 27 August 2024.
convenience and before the last day of the current care and early learning year, 27 August 2024.
Standard 8VAC20-780-140-A
Based on record review and interview, the center did not obtain a physical examination by or under the direction of a physician, before the child's attendance; or within 30 days after the first day of attendance.
Evidence: No physical exam was on file for Child #10. Director stated child has been in attendance for several years.
Evidence: No physical exam was on file for Child #10. Director stated child has been in attendance for several years.
Plan of Correction: The parents of child #10 have been contacted and requested to
provide the required most recent forms from the child's physician at their earliest possible convenience and no later than the last day of the current care and early
learning year, 28 August 2024
provide the required most recent forms from the child's physician at their earliest possible convenience and no later than the last day of the current care and early
learning year, 28 August 2024
Standard 8VAC20-780-245-A
Based on record review, staff have not obtained required 16 hours of annual training.
Evidence: Staff #1 who has been employed over 12 months, had no training hours documented in the file.
Evidence: Staff #1 who has been employed over 12 months, had no training hours documented in the file.
Plan of Correction: A log was created reflecting the professional growth and development hours staff #1 has participated in/completed during the 2023-2024 care and early learning year at the time of /on the day of the inspection.
Additionally, when staff #1 returns from scheduled leave, they will provide any and al I other training hours.
Additionally, when staff #1 returns from scheduled leave, they will provide any and al I other training hours.
Standard 8VAC20-780-260-B
Based on file review and interview, annual approval from the health department was not provided, for meeting requirements for water supply, sewage disposal system and food services.
Evidence: No Environmental Sanitation report was available at inspection.
Evidence: No Environmental Sanitation report was available at inspection.
Plan of Correction: FBCC CDC's Environmental Health Specialist has been contacted and requested to provide required Environmental Sanitation report at their earliest
convenience and/or before the last day of the current care and early learning year, 27 August 2024.
convenience and/or before the last day of the current care and early learning year, 27 August 2024.
Standard 8VAC20-780-500-A
Based on observation and interview, children's and staff hands were not washed with soap and running water after a diaper change.
Evidence:
Staff changed a child's diaper, removed gloves and then answered door to classroom without washing their hands or child's hands.
Evidence:
Staff changed a child's diaper, removed gloves and then answered door to classroom without washing their hands or child's hands.
Plan of Correction: With an understanding of the importance of hand hygiene and an
awareness of the violation which was called to their attention at the time of the
inspection, they approached the facility representative. Hand hygiene procedures for both adults and children were discussed. On 3 separate occasions since the
caregiver has been observed in compliance.
awareness of the violation which was called to their attention at the time of the
inspection, they approached the facility representative. Hand hygiene procedures for both adults and children were discussed. On 3 separate occasions since the
caregiver has been observed in compliance.
Standard 8VAC20-780-500-B
Based on observation and interview, a child's clothing that became wet, the child was not
cleaned and changed immediately.
Evidence: A child in the Butterflies classroom was dancing and interacting for several minutes without a shirt on. Staff reported child's clothing got wet and they are waiting for it to dry.
cleaned and changed immediately.
Evidence: A child in the Butterflies classroom was dancing and interacting for several minutes without a shirt on. Staff reported child's clothing got wet and they are waiting for it to dry.
Plan of Correction: Caregivers have been reminded of the importance of changing children's clothing when it becomes wet, dirty or soiled without unnecessary delay.
Standard 8VAC20-780-510-F
Based on record review, medication authorization was not available to staff during the entire time it is in effect.
Evidence: Medication Authorization for Child #7 was not signed by parent(s) or guardian.
Evidence: Medication Authorization for Child #7 was not signed by parent(s) or guardian.
Plan of Correction: Parent signed child #Ts *Medical Authorization Form (correction from submitted report) 9 August 2024.
Standard 8VAC20-780-510-P
Based on record review and interview, parent was not notified that medication had expired, medication was not picked up within 14 days and authorization was not renewed.
Evidence: Medication Authorization at the center expired 6/2024 for Child #6 and expired 3/2024 for Child #8.
Evidence: Medication Authorization at the center expired 6/2024 for Child #6 and expired 3/2024 for Child #8.
Plan of Correction: When child #8 returned to the FBCC CDC for care, the parents of
child #8 have been contacted to bring their attention and action to the matter of replacing and retrieving the expired medication.
child #8 have been contacted to bring their attention and action to the matter of replacing and retrieving the expired medication.
Standard 8VAC20-780-60-A
SYSTEMIC DEFICIENCY
Based on record review, the center did not maintain all required information in children's records.
Evidence:
1. Child #5's record did not have work phone number and place of employment of each parent
who has custody.
2. Child #2's record did not have name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
3. Child #7 and Child #8 written care plan for a diagnosed food allergy, to include
instructions from a physician regarding the food to which the child is allergic and
the steps to be taken in the event of a suspected or confirmed allergic reaction were not up to date.
4. Child 38 and Child #10's records did not have, documentation of viewing proof of the child's identity and age
Based on record review, the center did not maintain all required information in children's records.
Evidence:
1. Child #5's record did not have work phone number and place of employment of each parent
who has custody.
2. Child #2's record did not have name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
3. Child #7 and Child #8 written care plan for a diagnosed food allergy, to include
instructions from a physician regarding the food to which the child is allergic and
the steps to be taken in the event of a suspected or confirmed allergic reaction were not up to date.
4. Child 38 and Child #10's records did not have, documentation of viewing proof of the child's identity and age
Plan of Correction: The parent of child #5 has been contacted requesting required information (work phone number and place of employment) be submitted on or
before the last day of the current care and early learning year, 28 August 2024.
The parents of child #2 have been contacted requesting required
information (name, address and phone numbers of 2 designed persons to call in the event of an emergency when they are not available on or before the last day of the current care and early learning year.
The parent of child #7 and parents of child #8 have been contacted to request the required paperwork from the physician ensuring all information is up to date at their earliest possible convenience and before a specified date.
The parents of child #10 have been contacted and requested to
provide required proof of identity and age before the last day of the current care and early learning year, 27 August 2024.
before the last day of the current care and early learning year, 28 August 2024.
The parents of child #2 have been contacted requesting required
information (name, address and phone numbers of 2 designed persons to call in the event of an emergency when they are not available on or before the last day of the current care and early learning year.
The parent of child #7 and parents of child #8 have been contacted to request the required paperwork from the physician ensuring all information is up to date at their earliest possible convenience and before a specified date.
The parents of child #10 have been contacted and requested to
provide required proof of identity and age before the last day of the current care and early learning year, 27 August 2024.
Standard 8VAC20-780-70
REPEAT VIOLATION
Base on record review, the facility did not ensure that staff records were maintained with the required minimum information.
Evidence: Staff 1, employed since 12/11/23, did not have documentation of a second reference check.
Base on record review, the facility did not ensure that staff records were maintained with the required minimum information.
Evidence: Staff 1, employed since 12/11/23, did not have documentation of a second reference check.
Plan of Correction: The name and contact information of the additional reference is to be provided prior to the close of business 12 August 2024.