Inspection · 2022-08-08
Date
2022-08-08
Complaint Related
No
Licensing Inspector
Lauren Bickford
(540) 280-0742
(540) 280-0742
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minors records
22.1 Background Checks Code, Carbon Monoxide
22.1 Early Childhood Care and Education
Inspector Notes
An unannounced renewal inspection was initiated and concluded on 8/8/2022. The inspector was on site from 9:08 am-12:25 pm. There were 45 children present, ranging in ages from 11 months to 10 years, with 7 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, special care and emergencies, nutrition and background checks. A total of 5 child records, 6 staff records, and 2 officer records were reviewed.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.
Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.
Violations
9Standard 22.1-289.035-B-2
Based on a review of 6 staff records and interview, the center did not ensure to obtain the results of a fingerprint background check prior to the first date of employment for 4 staff as required.
Evidence:
1. The record of staff #2 (DOH: 5/31/2022) contained a fingerprint background check dated 6/3/2022. The record of staff #3 (DOH: 7/8/2022) contained a fingerprint background check dated 7/19/2022. The record of staff #4 (DOH: 4/21/2022) contained a fingerprint background check dated 5/2/2022. The record of staff #5 (DOH: 6/2/2022) contained a fingerprint background check dated 6/17/2022.
2. Administration acknowledged that the results were received after the first date of employment.
Evidence:
1. The record of staff #2 (DOH: 5/31/2022) contained a fingerprint background check dated 6/3/2022. The record of staff #3 (DOH: 7/8/2022) contained a fingerprint background check dated 7/19/2022. The record of staff #4 (DOH: 4/21/2022) contained a fingerprint background check dated 5/2/2022. The record of staff #5 (DOH: 6/2/2022) contained a fingerprint background check dated 6/17/2022.
2. Administration acknowledged that the results were received after the first date of employment.
Plan of Correction: Staff will not be hired unless all paperwork including fingerprint have been received.
Standard 22.1-289.058
Based on observation and interview, the center did not ensure that the building that was built prior to 2015 and serves preschool aged children was equipped with at least one carbon monoxide detector.
Evidence:
1. A carbon monoxide detector was not observed during the inspection on 8/8/2022.
2. Administration acknowledged that the center was not equipped with the detector.
Evidence:
1. A carbon monoxide detector was not observed during the inspection on 8/8/2022.
2. Administration acknowledged that the center was not equipped with the detector.
Plan of Correction: carbon monoxide detector has been put in the kitchen area.
Standard 8VAC20-770-60-B
Based on a review of 6 staff records and interview, the center did not ensure that 1 staff had a completed sworn statement prior to the first date of employment as required.
Evidence:
1. The record of staff #4 (DOH: 4/21/2022) contained a sworn statement dated 4/25/2022.
2. Administration acknowledged that the sworn statement was completed late.
Evidence:
1. The record of staff #4 (DOH: 4/21/2022) contained a sworn statement dated 4/25/2022.
2. Administration acknowledged that the sworn statement was completed late.
Plan of Correction: With further hires sworn disclosure will be completed at time of interview. Documentation will be done prior to hire.
Standard 8VAC20-770-60-C-2
Based on a review of 6 staff records and interview, the center did not ensure to obtain the results of a central registry background check by the end of the 30th day for 5 staff as required.
Evidence:
1. The record of staff #2 (DOH: 5/31/2022) did not contain the results of a central registry background check. The record of staff #3 (DOH: 7/8/2022) did not contain the results of a central registry background check. The record of staff #4 (DOH: 4/21/2022) contained central registry results dated 5/26/2022. The record of staff #5 (DOH: 6/2/2022) did not contain the results of a central registry background check. The record of staff #6 (DOH: 10/18/2021) contained a central registry background check dated 12/16/2021.
2. Administration acknowledged that the results were not received within the required time frame.
Evidence:
1. The record of staff #2 (DOH: 5/31/2022) did not contain the results of a central registry background check. The record of staff #3 (DOH: 7/8/2022) did not contain the results of a central registry background check. The record of staff #4 (DOH: 4/21/2022) contained central registry results dated 5/26/2022. The record of staff #5 (DOH: 6/2/2022) did not contain the results of a central registry background check. The record of staff #6 (DOH: 10/18/2021) contained a central registry background check dated 12/16/2021.
2. Administration acknowledged that the results were not received within the required time frame.
Plan of Correction: Central registry has been contacted for a copy of the forms for each staff. Staff names, checks numbers, and date of check was provided. In a future a follow up will be made to ensure registries are received on time.
Standard 8VAC20-780-130-A
Based on a review of 5 children?s records and interview, the center did not ensure to obtain documentation that one (1) child had received the immunizations required by the State Board of Health before the first date of enrollment (DOE) as required.
Evidence:
1. The record of child # 3 (DOE: 6/1/2022) did not contain an immunization record.
2. Administration acknowledged that the record was not received.
Evidence:
1. The record of child # 3 (DOE: 6/1/2022) did not contain an immunization record.
2. Administration acknowledged that the record was not received.
Plan of Correction: Before date of entry of any child coming to FOFA the health form will be received before date of admittance.
Standard 8VAC20-780-140-A
Based on a review of five (5) children?s records and interview, the center did not ensure that one (1) child had 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:
1. The record of child # 3, first day of attendance 6/1/2022, did not contain a physical record.
2. Administration acknowledged that the record was not received.
Evidence:
1. The record of child # 3, first day of attendance 6/1/2022, did not contain a physical record.
2. Administration acknowledged that the record was not received.
Plan of Correction: The dad of the child was contacted he understands the child may not return until a completed physical has been completed.
Standard 8VAC20-780-160-A
Based on a review of 6 staff records and interview, the center did not ensure to obtain documentation of a negative tuberculosis screening for 5 staff that fell within the required time frames. Documentation of the screening must be submitted 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 and be signed by a physician, physician's designee, or an official of the local health department.
Evidence:
1. The record of staff #2 (DOE: 5/31/2022) contained a TB screening dated 6/15/2020. The record of staff #3 (DOE: 7/8/2022) contained a TB screening dated 7/20/2022. The record of staff #4 (DOE: 4/21/2022) contained a TB screening dated 6/14/2022. The record of staff 5 (DOE: 6/2/2022) contained a TB screening dated 6/15/2022. The record of staff #6 (DOE: 10/18/2021) contained a TB screening dated 10/19/2021).
2. Administration acknowledged that the TB screenings were not completed within the required time frame.
Evidence:
1. The record of staff #2 (DOE: 5/31/2022) contained a TB screening dated 6/15/2020. The record of staff #3 (DOE: 7/8/2022) contained a TB screening dated 7/20/2022. The record of staff #4 (DOE: 4/21/2022) contained a TB screening dated 6/14/2022. The record of staff 5 (DOE: 6/2/2022) contained a TB screening dated 6/15/2022. The record of staff #6 (DOE: 10/18/2021) contained a TB screening dated 10/19/2021).
2. Administration acknowledged that the TB screenings were not completed within the required time frame.
Plan of Correction: TB screenings will be secured by FOFA before staff are able to begin employment.
Standard 8VAC20-780-330-B
Based on observation on 08/08/2022, the center did not ensure that where playground equipment is provided, resilient surfacing shall comply with minimum safety standards.
Evidence:
1) During the inspection of the playground, the licensing inspector measured pea gravel under and around the slides and climber on the preschool playground. Three pea gravel samplings measured approximately 2 to 4 inches in depth. The equipment requires at least six inches of resilient surfacing.
2) Administration acknowledged that the equipment would require additional resilient surfacing.
Evidence:
1) During the inspection of the playground, the licensing inspector measured pea gravel under and around the slides and climber on the preschool playground. Three pea gravel samplings measured approximately 2 to 4 inches in depth. The equipment requires at least six inches of resilient surfacing.
2) Administration acknowledged that the equipment would require additional resilient surfacing.
Plan of Correction: Rocks on the playground will be put in the fall zones by the end of the week.
Standard 8VAC20-780-70
Based on a review of 6 staff records and interview, the center did not ensure that complete staff records were kept for four (4) staff persons.
Evidence:
1. The staff records of staff #2 (DOH: 5/31/2022), staff #3 (DOH: 7/8/2022), staff #4 (DOH: 4/21/2022) and staff #5 (DOH: 6/2/2022) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment as required.
2. Administration acknowledged that the references were not documented as part of the record.
Evidence:
1. The staff records of staff #2 (DOH: 5/31/2022), staff #3 (DOH: 7/8/2022), staff #4 (DOH: 4/21/2022) and staff #5 (DOH: 6/2/2022) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment as required.
2. Administration acknowledged that the references were not documented as part of the record.
Plan of Correction: References that were in the staff file were not in depth as licensing accepts. in the future references will be documented on VDOE forms so they are in compliance.