Inspection · 2023-07-13
Date
2023-07-13
Complaint Related
No
Licensing Inspector
Rebecca Forestier
(540) 309-2835
(540) 309-2835
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
8VAC20-770 BACKGROUND CHECKS
20 ACCESS TO MINOR?S RECORDS
22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE
Inspector Notes
An unannounced renewal inspection was conducted on 07/13/2023. There were 18 children, ages 3 months-5 years, and 10 staff members present during the inspection. The inspector reviewed compliance in the areas of administration, staff qualifications and trainings, staffing and supervision, physical plant, programs, emergencies and nutrition. The children were observed in the following: during breakfast and participating in free choice activities. A total of 5 children?s records, 5 staff records, and 1 applicant record were reviewed. The inspector discussed the following with staff: emergency preparedness plans and policies/procedures. The inspector arrived for the inspection at 8:10 am and departed at 1:15 pm.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider.
Violations
7Standard 8VAC20-780-130-A
Based on record review, 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: Staff 7 verified that the first day of attendance for Child 2 was 03/13/2023. The date on the immunization record was 03/20/2023. The immunization record was not obtained before the child attended the center.
Evidence: Staff 7 verified that the first day of attendance for Child 2 was 03/13/2023. The date on the immunization record was 03/20/2023. The immunization record was not obtained before the child attended the center.
Plan of Correction: Will get immunization records at the time of enrollment.
Standard 8VAC20-780-130-E
Based on record review, the center failed to obtain documentation of additional immunizations once every six months for children under the age of two years.
Evidence: The record for Child 1 contained a documented start date of 07/12/2021. The most recent immunization record in the record for Child 1 was dated 08/10/2022; additional immunizations were not obtained every 6 months from 08/10/2022 until the child turned 2 years old.
Evidence: The record for Child 1 contained a documented start date of 07/12/2021. The most recent immunization record in the record for Child 1 was dated 08/10/2022; additional immunizations were not obtained every 6 months from 08/10/2022 until the child turned 2 years old.
Plan of Correction: Will get updated immunization records every 6 months for children under years old.
Standard 8VAC20-780-340-C
Based on staff interviews, the center failed to ensure that during the stated hours of operation, there always shall be on the premises and on field trips when one or more children are present one staff member who meets the qualification of program leader or program director and an immediately available staff member, volunteer or other employee who is at least 16 years of age with direct means for communication between the two of them.
Evidence:
1. Staff 5 stated that they were the only staff member on the premises from 6:30 am- approximately 6:45 am when Staff 3 arrived. Staff 5 stated that they had two children in care during that time.
2. Staff 3 stated that they observed Staff 5 alone with children upon their arrival to the center at approximately 6:45 am.
Evidence:
1. Staff 5 stated that they were the only staff member on the premises from 6:30 am- approximately 6:45 am when Staff 3 arrived. Staff 5 stated that they had two children in care during that time.
2. Staff 3 stated that they observed Staff 5 alone with children upon their arrival to the center at approximately 6:45 am.
Plan of Correction: Will have 2 people here at all time or will instruct the staff to not open the center until a 2nd person arrives.
Standard 8VAC20-780-530-C
Based on staff interviews, the center failed to ensure that there shall be at least two staff members who have a current certification in CPR and first aid present and on the premises during the center?s hours of operation, on fieldtrips and wherever children are in care.
Evidence: Staff 5 stated that they were the only staff member on the premises from 6:30 am- approximately 6:45 am. Staff 5 stated that they had two children in care during that time. Staff 5 was the only staff member on the premises during that time with a current certification in CPR and first aid.
Evidence: Staff 5 stated that they were the only staff member on the premises from 6:30 am- approximately 6:45 am. Staff 5 stated that they had two children in care during that time. Staff 5 was the only staff member on the premises during that time with a current certification in CPR and first aid.
Plan of Correction: Will have 2 people on site at all times.
Standard 8VAC20-780-70
REPEAT VIOLATION
Based on record review, the center failed to ensure that staff records contain all of the elements as required by the standards.
Evidence:
1. The record for Staff 1 did not contain the following information: documentation that the individual possesses the education, certification and experience required by the job position (the record contained a documented job position of program leader); and documentation that two or more references as to character and reputation as well as competency were checked before employment and that documentation of references taken over the phone contain all of the elements as required by the standards (one of the references did not contain the signature of the person making the call).
2. The record for Staff 3 did not contain the following information: documentation that two or more references as to character and reputation as well as competency were checked before employment and that documentation of references taken over the phone contain all of the elements as required by the standards (one of the references did not contain the name of the person contacted).
3. The record for Staff 4 did not contain the following information: documentation that the individual possesses the education, certification and experience required by the job position (the record contained a documented job position of program leader).
4. The record for Staff 5 did not contain the following information: documentation that the individual possesses the education, certification and experience required by the job position (the record contained a documented job position of program leader).
Based on record review, the center failed to ensure that staff records contain all of the elements as required by the standards.
Evidence:
1. The record for Staff 1 did not contain the following information: documentation that the individual possesses the education, certification and experience required by the job position (the record contained a documented job position of program leader); and documentation that two or more references as to character and reputation as well as competency were checked before employment and that documentation of references taken over the phone contain all of the elements as required by the standards (one of the references did not contain the signature of the person making the call).
2. The record for Staff 3 did not contain the following information: documentation that two or more references as to character and reputation as well as competency were checked before employment and that documentation of references taken over the phone contain all of the elements as required by the standards (one of the references did not contain the name of the person contacted).
3. The record for Staff 4 did not contain the following information: documentation that the individual possesses the education, certification and experience required by the job position (the record contained a documented job position of program leader).
4. The record for Staff 5 did not contain the following information: documentation that the individual possesses the education, certification and experience required by the job position (the record contained a documented job position of program leader).
Plan of Correction: Will make sure that training is documented and make sure that all things are signed accordingly.
Standard 8VAC20-780-80-A
Based on document review and discussion with staff, the center failed to ensure that for each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
Evidence: The attendance record in the 2 year old-pre-k classroom indicated there were 9 children present. There were 7 children observed in the group at the time the attendance record was reviewed. The attendance did not document departure as it occurred.
Evidence: The attendance record in the 2 year old-pre-k classroom indicated there were 9 children present. There were 7 children observed in the group at the time the attendance record was reviewed. The attendance did not document departure as it occurred.
Plan of Correction: Will retrain on the child attendance policy.
Standard 8VAC20-780-80-B-2
Based on staff interviews, the center failed to ensure that the center shall inform the department?s representative as soon as practicable, but not to exceed two business days, of any injury to a child that occurs while the child is under the supervision of the center and requires outside medical attention.
Evidence: Statements from Staff 1, Staff 2, Staff 6, and Staff 7 verified that Child 2 was involved in an incident while under the supervision of the center on 05/10/2023 that resulted in Child 2 requiring outside medical attention. As of the date of the inspection, 07/13/2023, the center had not notified the department?s representative of the incident.
Evidence: Statements from Staff 1, Staff 2, Staff 6, and Staff 7 verified that Child 2 was involved in an incident while under the supervision of the center on 05/10/2023 that resulted in Child 2 requiring outside medical attention. As of the date of the inspection, 07/13/2023, the center had not notified the department?s representative of the incident.
Plan of Correction: Will notify the inspector in a timely manner if a child required outside medical care.