Inspection · 2024-04-26
Date
2024-04-26
Complaint Related
No
Licensing Inspector
Brandie Viscayda
(757) 636-3427
(757) 636-3427
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 monitoring inspection was initiated on 04/26/2024 at 3:25 pm and completed on 04/26/2024 at 6:10 pm.
At the time of the tour there were 53 children in care with 13 staff supervising. The children in care ranged in age from infant - four years.
Children were observed during afternoon program time which included table games, group time and free play. Diapering was observed in the infant, toddler and two-year old classrooms. Records were reviewed for five staff and five children.
The information gathered determined violations with applicable standards and law. These violations are listed on the violation notice issued to the facility and were reviewed with the program director at the conclusion of the inspection.
Violations
14Standard 8VAC20-770-60-B
Based on record review and interview, the center failed to ensure that an employee of a child day program must not be employed until the agency or home has the person's completed sworn statement or affirmation.
Evidence:
1. There was no sworn statement or affirmation on file for staff 4 who was observed working in the program during the inspection.
2. The sworn statement or affirmation for staff 1, staff 2, and staff 3 were not dated therefore, no determination could be made as to if each was completed at the time of employment.
3. The program director confirmed that the sworn statements were missing and / or incomplete.
Evidence:
1. There was no sworn statement or affirmation on file for staff 4 who was observed working in the program during the inspection.
2. The sworn statement or affirmation for staff 1, staff 2, and staff 3 were not dated therefore, no determination could be made as to if each was completed at the time of employment.
3. The program director confirmed that the sworn statements were missing and / or incomplete.
Plan of Correction: The director stated that each staff would complete and date a current sworn statement or affirmation.
Standard 8VAC20-770-60-C-2
Based on record review and interview, the center failed to ensure that staff have a central registry finding within 30 days of employment.
Evidence:
1. Staff 2, approximate hire date of 07/2023, lacks the results of a central registry check.
2. Staff 3, approximate hire date of 03/2024, lacks the results of a central registry check.
3. Staff 4, approximate hire date of 03/05/2024, lacks the results of a central registry check.
4. The program director confirmed that central registry checks were not on file for these staff.
Evidence:
1. Staff 2, approximate hire date of 07/2023, lacks the results of a central registry check.
2. Staff 3, approximate hire date of 03/2024, lacks the results of a central registry check.
3. Staff 4, approximate hire date of 03/05/2024, lacks the results of a central registry check.
4. The program director confirmed that central registry checks were not on file for these staff.
Plan of Correction: The director stated that a central registry check would be obtained for all staff.
Standard 8VAC20-780-130-A
Based on record review and interview, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence:
1. Immunization information was not on file for child 1 who has an enrollment date of 09/12/2023.
2. The program director confirmed that documentation of required immunizations were not on file for child 1.
Evidence:
1. Immunization information was not on file for child 1 who has an enrollment date of 09/12/2023.
2. The program director confirmed that documentation of required immunizations were not on file for child 1.
Plan of Correction: The director stated the immunization information would be requested.
Standard 8VAC20-780-140-A
Based on record review and interview, the center failed to ensure that each child shall have a physical examination by or under the direction of a physician before attendance or within 30 days after the first day of attendance.
Evidence:
1. Child 1, enrollment date 09/12/2023, lacked documentation of a physical exam.
2. The program director confirmed that documentation of a physical exam was not on file for child 1.
Evidence:
1. Child 1, enrollment date 09/12/2023, lacked documentation of a physical exam.
2. The program director confirmed that documentation of a physical exam was not on file for child 1.
Plan of Correction: The director stated the a documented physical exam would be requested.
Standard 8VAC20-780-160-A
Based on record review and interview, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence:
1. There was no TB screening on file for staff 3. Staff 3 was observed working in the facility during the inspection and has an approximate hire date of 03/2024.
2. There was no TB screening on file for staff 4. Staff 4 was observed working in the facility during the inspection and has an approximate hire date of 03/05/2024.
3. The program director confirmed that a TB screening was not on file for staff 3 and staff 4.
Evidence:
1. There was no TB screening on file for staff 3. Staff 3 was observed working in the facility during the inspection and has an approximate hire date of 03/2024.
2. There was no TB screening on file for staff 4. Staff 4 was observed working in the facility during the inspection and has an approximate hire date of 03/05/2024.
3. The program director confirmed that a TB screening was not on file for staff 3 and staff 4.
Plan of Correction: The director stated that each staff would obtain a current TB screening.
Standard 8VAC20-780-260-A
Based on record review and interview, the center failed to provide to the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction.
Evidence:
1. The most recent inspection from the Norfolk Fire Marshall was conducted on 02/03/2023.
2. The program director confirmed this as the most recent inspection.
Evidence:
1. The most recent inspection from the Norfolk Fire Marshall was conducted on 02/03/2023.
2. The program director confirmed this as the most recent inspection.
Plan of Correction: The director stated that an annual fire inspection would be requested.
Standard 8VAC20-780-270-A
Based on observation, the center failed to ensure that areas and equipment of the center, inside and outside, shall be maintained in a safe condition. Unsafe conditions shall include, but not be limited to, splintered, cracked or otherwise deteriorating wood; chipped or peeling paint; visible cracks, bending or warping, rusting or breakage of any equipment; head entrapment hazards; and protruding nails, bolts or other components that could entangle clothing or snag skin.
Evidence:
1. The following safety hazards were observed in the infant classroom:
a. Dangling cords from infant swings and infant seats are a trip hazard.
b. One crib with a manufacture date of 04/2010 is not compliant with current CPSC guidelines which requires all cribs to be manufactured on or after 06/28/2011.
c. Two additional cribs lacked any type of label or certificate to determine if they meet current CPSC guidelines.
d. A significate rip was observed in the cloth seat of an infant bouncy seat.
2. The microwave oven placed on top of the refrigerator in the green classroom is a toppling hazard.
3. The cuppy storage unit in the silver classroom is a toppling hazard as it has not been secured to the wall.
4. The rubber / carpet at the entrance to the blue classroom is not secured creating a trip hazard.
5. Two bags of trash containing food and soiled diapers was observed on the floor of the bathroom for the green classroom at approximately 4:15 pm.
6. The large playground has areas of uneven ground which create a potential trip hazard.
a. Multiple areas of weeds need to be cut.
b. The plastic outdoor play cube has several areas of cracked plastic which creates a pinch point hazard.
Evidence:
1. The following safety hazards were observed in the infant classroom:
a. Dangling cords from infant swings and infant seats are a trip hazard.
b. One crib with a manufacture date of 04/2010 is not compliant with current CPSC guidelines which requires all cribs to be manufactured on or after 06/28/2011.
c. Two additional cribs lacked any type of label or certificate to determine if they meet current CPSC guidelines.
d. A significate rip was observed in the cloth seat of an infant bouncy seat.
2. The microwave oven placed on top of the refrigerator in the green classroom is a toppling hazard.
3. The cuppy storage unit in the silver classroom is a toppling hazard as it has not been secured to the wall.
4. The rubber / carpet at the entrance to the blue classroom is not secured creating a trip hazard.
5. Two bags of trash containing food and soiled diapers was observed on the floor of the bathroom for the green classroom at approximately 4:15 pm.
6. The large playground has areas of uneven ground which create a potential trip hazard.
a. Multiple areas of weeds need to be cut.
b. The plastic outdoor play cube has several areas of cracked plastic which creates a pinch point hazard.
Plan of Correction: The director stated the old cribs would be removed and replaced with new ones that meet current CPSC guidelines.
The infant seat with the rip will be discarded.
Dangling cords will be removed and/or secured.
The trash was removed from the bathroom during the inspection.
The rug will be secured to the floor and the cubby/microwave will be secured to ensure they do not fall.
The weeds will be removed from the outdoor play area. The uneven areas of the ground will be filled and cube with cracks removed.
The infant seat with the rip will be discarded.
Dangling cords will be removed and/or secured.
The trash was removed from the bathroom during the inspection.
The rug will be secured to the floor and the cubby/microwave will be secured to ensure they do not fall.
The weeds will be removed from the outdoor play area. The uneven areas of the ground will be filled and cube with cracks removed.
Standard 8VAC20-780-280-D
Based on observation, the center failed to ensure that cleaning and sanitizing materials shall not be located above food, food equipment, utensils or single-service articles and shall be stored in areas physically separate from food.
Evidence:
1. In the silver classroom a spray bottle of bleach and water solution was observed stored inside of a cabinet near a container of unpropped popcorn.
Evidence:
1. In the silver classroom a spray bottle of bleach and water solution was observed stored inside of a cabinet near a container of unpropped popcorn.
Plan of Correction: Staff will be reminded to not to place cleaning agents in the same cabinet near/beside food. This was corrected during the inspection.
Standard 8VAC20-780-500-B
Based on observation, the center failed to ensure that the diapering surface shall be cleaned with soap and at least room temperature water and sanitized after each use.
The definition of sanitized means the surface of the item is sprayed with the disinfectant solution and allowed to air dry on the surface for a minimum of two minutes.
Evidence:
1. The diaper changing table in the two-year old classroom was not cleaned with soap and water after completion of a diaper change at 4:05 pm.
2. The diaper changing table was not allowed to air dry for at least two minutes after the completion of 2 diaper changes at approximately 3:55 pm in the orange classroom.
a. The surface of the diaper changing table was immediately wiped with a paper towel after the bleach and water solution was sprayed.
The definition of sanitized means the surface of the item is sprayed with the disinfectant solution and allowed to air dry on the surface for a minimum of two minutes.
Evidence:
1. The diaper changing table in the two-year old classroom was not cleaned with soap and water after completion of a diaper change at 4:05 pm.
2. The diaper changing table was not allowed to air dry for at least two minutes after the completion of 2 diaper changes at approximately 3:55 pm in the orange classroom.
a. The surface of the diaper changing table was immediately wiped with a paper towel after the bleach and water solution was sprayed.
Plan of Correction: Cleaning and Sanitizing procedures reviewed with staff during the inspection.
Standard 8VAC20-780-560-G
Based on observation, the center failed to ensure that when food is brought from home, the food container shall be clearly dated.
Evidence:
1. 5 of 12 cans of infant formula lacked a date indicating when the formula was received into the infant classroom.
2. A bottle of juice, in the older infant classroom, was not dated.
Evidence:
1. 5 of 12 cans of infant formula lacked a date indicating when the formula was received into the infant classroom.
2. A bottle of juice, in the older infant classroom, was not dated.
Plan of Correction: All cans of formula have been dated. Bottles of juice will be dated when they come in with each child.
Standard 8VAC20-780-570-A
Based on observation, the center failed to ensure that when a child is placed in an infant seat or high chair, the protective belt shall be fastened securely.
Evidence:
1. Six children in the orange classroom were observed sitting inside of infant table seats without the safety belt fastened.
Evidence:
1. Six children in the orange classroom were observed sitting inside of infant table seats without the safety belt fastened.
Plan of Correction: Staff will be reminded to engage safety strap when high chairs and table chairs are occupied.
Standard 8VAC20-780-60-A
Based on record review and interview, the center failed to ensure that children's records contain all of the required elements.
Evidence:
1. The enrollment record for child 1, enrollment date 09/12/2023, lacked documentation of viewing proof of the child's identity and age.
2. The enrollment record for child 2, enrollment date 10/27/2023, lacked documentation of the following:
a. Phone number for one parent;
b. Work phone number for one parent;
c. Work phone number and place of employment for the other parent.
3. The enrollment record for child 3, enrollment date 09/22/2023, lacked the work phone number for both parent's.
4, The enrollment record for child 4, enrollment date 10/20/2023, lacked the work phone number for one parent.
5. The enrollment record for child 5, enrollment date 02/23/2023, lacked the work phone number for both parents.
6. The program director confirmed the above information was not available.
Evidence:
1. The enrollment record for child 1, enrollment date 09/12/2023, lacked documentation of viewing proof of the child's identity and age.
2. The enrollment record for child 2, enrollment date 10/27/2023, lacked documentation of the following:
a. Phone number for one parent;
b. Work phone number for one parent;
c. Work phone number and place of employment for the other parent.
3. The enrollment record for child 3, enrollment date 09/22/2023, lacked the work phone number for both parent's.
4, The enrollment record for child 4, enrollment date 10/20/2023, lacked the work phone number for one parent.
5. The enrollment record for child 5, enrollment date 02/23/2023, lacked the work phone number for both parents.
6. The program director confirmed the above information was not available.
Plan of Correction: The director stated that all missing information would be obtained for children's records.
Standard 8VAC20-780-70
Based on record review and interview, the center failed to ensure that staff records contain all of the required elements.
Evidence:
1. The employment record for staff 5 and staff 6 could not be located.
2. The employment record for staff 1, staff 2, staff 3 and staff 4 lacked documentation of the date of employment.
3. The employment record for staff 2, staff 3, staff 4 and staff 7 lacked documentation of a job title.
4. The employment record for staff 3 and staff 4 lacked documentation of completion of orientation training.
5. The employment record for staff 3 and staff 4 lacked documentation of two reference checks.
Evidence:
1. The employment record for staff 5 and staff 6 could not be located.
2. The employment record for staff 1, staff 2, staff 3 and staff 4 lacked documentation of the date of employment.
3. The employment record for staff 2, staff 3, staff 4 and staff 7 lacked documentation of a job title.
4. The employment record for staff 3 and staff 4 lacked documentation of completion of orientation training.
5. The employment record for staff 3 and staff 4 lacked documentation of two reference checks.
Plan of Correction: The director stated that staff records would be updated to include all required information.
The director stated that the files for staff 5 and 6 would be located and placed in file cabinet at the center.
The director stated that the files for staff 5 and 6 would be located and placed in file cabinet at the center.
Standard 8VAC20-780-90-A
Based on record review and interview, the center failed to ensure that a written agreement between the parent and the center shall be in each child's record by the first day of the child's attendance. The agreement shall be signed by the parent.
Evidence:
1. The written parent agreement was not on file for child 1 who has an enrollment date of 09/12/2013.
2. The program director confirmed that a signed parent agreement was not on file for child 1.
Evidence:
1. The written parent agreement was not on file for child 1 who has an enrollment date of 09/12/2013.
2. The program director confirmed that a signed parent agreement was not on file for child 1.
Plan of Correction: The director stated that a written parent agreement would be provided to the parent and documentation placed in the child's file.