Inspection · 2024-07-29
Date
2024-07-29
Complaint Related
No
Licensing Inspector
Florence Martus
(804) 389-0157
(804) 389-0157
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 Early Childhood Care and Education
32.1 Report by person other than physician
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced, on-site renewal inspection was initiated on 07/29/2024 and completed on 08/05/2024, as a part of the licensure period. On 07/29/24, the on-site inspection began at 11:10am and ended at 3:45pm. The inspector reviewed compliance in the areas listed above. There were 133 children present and 24 staff. The inspector reviewed 10 children?s records and 10 staff records on-site. An additional 23 staff records were reviewed on-site on 08/05/2024. This inspection included document review, 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 09/03/2024.
Violations
13Standard 22.1-289.035-A
Based on a review of 33 staff records and interviews, the center did not ensure that two staff members shall undergo background checks every five years.
Evidence:
1. The most recent national fingerprint-based criminal background check in the record of Staff #11 was obtained on 07/19/24. The previous national fingerprint-based criminal background check was obtained on 10/09/18 and should have been repeated no later than 10/09/23.
2. The most recent central registry finding in the record of Staff #11 was obtained on 06/20/24. The previous central registry finding was obtained on 12/02/18 and should have been repeated no later than 12/02/23.
3. The most recent central registry finding in the record of Staff #25 was obtained on 07/24/24. The previous central registry finding was obtained on 05/17/19 and should have been repeated no later than 05/17/24.
4. During interviews, management acknowledged the background checks were not obtained every five years as required.
Evidence:
1. The most recent national fingerprint-based criminal background check in the record of Staff #11 was obtained on 07/19/24. The previous national fingerprint-based criminal background check was obtained on 10/09/18 and should have been repeated no later than 10/09/23.
2. The most recent central registry finding in the record of Staff #11 was obtained on 06/20/24. The previous central registry finding was obtained on 12/02/18 and should have been repeated no later than 12/02/23.
3. The most recent central registry finding in the record of Staff #25 was obtained on 07/24/24. The previous central registry finding was obtained on 05/17/19 and should have been repeated no later than 05/17/24.
4. During interviews, management acknowledged the background checks were not obtained every five years as required.
Plan of Correction: Per the Center: "The management interviewed at the time of inspection was responsible for the submission of the background checks that caused the 2 staff member's files to be returned to compliance at the time of the inspection.
The management responsible for the lack of timely resubmission of the background checks has separated from the company."
The management responsible for the lack of timely resubmission of the background checks has separated from the company."
Standard 22.1-289.035-B-2
(REPEAT VIOLATION/SYSTEMIC VIOLATION) Based on a review of 33 staff records and interviews, the center did not obtain a national fingerprint-based criminal record search for seven staff members prior to employment.
Evidence:
1. The national fingerprint-based criminal record search in the record of Staff #3, date of employment 02/09/24, was obtained on 02/27/24.
2. The national fingerprint-based criminal record search in the record of Staff #12, date of employment 08/14/23, was obtained on 08/15/23.
3. The national fingerprint-based criminal record search in the record of Staff #18, date of employment 02/19/24, was obtained on 02/20/24.
4. The national fingerprint-based criminal record search in the record of Staff #22, date of employment 01/14/24, was obtained on 01/17/24.
5. The national fingerprint-based criminal record search in the record of Staff #24, date of employment 08/04/23, was obtained on 08/08/23.
6. The national fingerprint-based criminal record search in the record of Staff #28, date of employment 01/29/24, was obtained on 02/07/24.
7. The national fingerprint-based criminal record search in the record of Staff #29, date of employment 01/28/24, was obtained on 02/06/24.
8. During interviews, management confirmed the fingerprints were obtained after employment.
Evidence:
1. The national fingerprint-based criminal record search in the record of Staff #3, date of employment 02/09/24, was obtained on 02/27/24.
2. The national fingerprint-based criminal record search in the record of Staff #12, date of employment 08/14/23, was obtained on 08/15/23.
3. The national fingerprint-based criminal record search in the record of Staff #18, date of employment 02/19/24, was obtained on 02/20/24.
4. The national fingerprint-based criminal record search in the record of Staff #22, date of employment 01/14/24, was obtained on 01/17/24.
5. The national fingerprint-based criminal record search in the record of Staff #24, date of employment 08/04/23, was obtained on 08/08/23.
6. The national fingerprint-based criminal record search in the record of Staff #28, date of employment 01/29/24, was obtained on 02/07/24.
7. The national fingerprint-based criminal record search in the record of Staff #29, date of employment 01/28/24, was obtained on 02/06/24.
8. During interviews, management confirmed the fingerprints were obtained after employment.
Plan of Correction: Per the Center: "The 7 staff files that did not contain a national fingerprint-based criminal record search prior to starting employment did contain completed searches at the time of inspection. The management responsible for the records out of compliance with time frame for submission requirements has separated from the company.
Management interviewed at the time of inspection will continue to maintain compliance with criminal search time frames as described in the standard."
Management interviewed at the time of inspection will continue to maintain compliance with criminal search time frames as described in the standard."
Standard 22.1-289.035-B-4
(REPEAT VIOLATION/SYSTEMIC VIOLATION) Based on a review of 33 staff records and interviews, the center did not obtain the required out-of-state background checks from any state in which five staff members had resided in the preceding five years within the required timeframe.
Evidence:
1.The record of Staff #1, date of employment 01/15/24, indicated the staff had resided in another state outside of Virginia within the last five years. The search of the child abuse and neglect registry was requested on 03/05/24 and the results received on 03/25/24.
2. The record of Staff #3, date of employment 02/19/24, indicated the staff had resided in two states outside of Virginia within the last five years. The record did not contain a copy of the results of the criminal history record information check for one of the states, or a search of the child abuse and neglect registry or equivalent registry from both states.
3. A sworn statement completed on 04/03/23 in the record of Staff #7, date of employment 04/03/23, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain a copy of the results of the criminal history record information check, or a search of the child abuse and neglect registry or equivalent registry from that state.
4. The record of Staff #21, date of employment 02/19/24, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain the search of the child abuse and neglect registry or equivalent registry from that state.
5. The record of Staff #28, date of employment 01/29/24, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain the search of the child abuse and neglect registry or equivalent registry from that state.
6. During interviews, management acknowledged the background checks on file were the only out-of-state background checks that could be located for each staff member.
For staff employed prior to July 1, 2024, the out-of-state search of the child abuse and neglect registry was required to be requested within 30 days of employment. The out-of-state criminal history record information check is required to be obtained prior to employment.
Evidence:
1.The record of Staff #1, date of employment 01/15/24, indicated the staff had resided in another state outside of Virginia within the last five years. The search of the child abuse and neglect registry was requested on 03/05/24 and the results received on 03/25/24.
2. The record of Staff #3, date of employment 02/19/24, indicated the staff had resided in two states outside of Virginia within the last five years. The record did not contain a copy of the results of the criminal history record information check for one of the states, or a search of the child abuse and neglect registry or equivalent registry from both states.
3. A sworn statement completed on 04/03/23 in the record of Staff #7, date of employment 04/03/23, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain a copy of the results of the criminal history record information check, or a search of the child abuse and neglect registry or equivalent registry from that state.
4. The record of Staff #21, date of employment 02/19/24, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain the search of the child abuse and neglect registry or equivalent registry from that state.
5. The record of Staff #28, date of employment 01/29/24, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain the search of the child abuse and neglect registry or equivalent registry from that state.
6. During interviews, management acknowledged the background checks on file were the only out-of-state background checks that could be located for each staff member.
For staff employed prior to July 1, 2024, the out-of-state search of the child abuse and neglect registry was required to be requested within 30 days of employment. The out-of-state criminal history record information check is required to be obtained prior to employment.
Plan of Correction: Per the Center: "Staff #3, #7, and #28 have been submitted and will have out of state background checks completed in compliance with 22.1-(14.1)-289.035-B-4 by 9/30/24.
Staff #21 has had their out of state background check completed in compliance with 22.1-(14.1)-289.035-B-4 as of 7/23/24.
Management interviewed at the time of inspection will maintain compliance in completing timely out of state background checks where required.
Management responsible for the lack of submission of out of state background checks has separated from the company."
Staff #21 has had their out of state background check completed in compliance with 22.1-(14.1)-289.035-B-4 as of 7/23/24.
Management interviewed at the time of inspection will maintain compliance in completing timely out of state background checks where required.
Management responsible for the lack of submission of out of state background checks has separated from the company."
Standard 8VAC20-770-60-B
(REPEAT VIOLATION) Based on a review of 33 staff records and interviews, the center did not ensure that two staff members had a completed sworn statement or affirmation prior to employment.
Evidence:
1. The sworn statement in the record of Staff #3, date of employment 02/19/24, was completed on 04/18/24.
2. The sworn statement in the record of Staff #29, date of employment 01/28/24, was completed on 01/29/24.
3. During interviews, management acknowledged the sworn statements on file for Staff #3 and Staff #29 were completed after employment.
Evidence:
1. The sworn statement in the record of Staff #3, date of employment 02/19/24, was completed on 04/18/24.
2. The sworn statement in the record of Staff #29, date of employment 01/28/24, was completed on 01/29/24.
3. During interviews, management acknowledged the sworn statements on file for Staff #3 and Staff #29 were completed after employment.
Plan of Correction: Per the Center: "Staff #29 signed 1 day after start of employment. Staff #3 signed upon internal audit revealing the absence of a completed form.
Management that was interviewed at the time of inspection was the person responsible for conducting the internal audit, and also the person responsible for immediately bringing the forms into compliance upon discovery. Management will continue to maintain staff files in compliance.
Management responsible for the incomplete forms has separated from the company."
Management that was interviewed at the time of inspection was the person responsible for conducting the internal audit, and also the person responsible for immediately bringing the forms into compliance upon discovery. Management will continue to maintain staff files in compliance.
Management responsible for the incomplete forms has separated from the company."
Standard 8VAC20-770-60-C-2
(REPEAT VIOLATION) Based on a review of 33 staff records and interviews, the center did not ensure that five staff members had a central registry finding within 30 days of employment.
Evidence:
1. The central registry finding in the record of Staff #8, date of employment 10/03/22, was dated 01/04/23.
2. The central registry finding in the record of Staff #13, date of employment 06/05/23, was dated 09/04/23.
3. The record of Staff #19, employed on 08/16/21, did not contain documentation of a central registry finding.
4. The central registry finding in the record of Staff #20, date of employment 10/03/22, was dated 01/04/23.
5. The record of Staff #23, employed on 03/26/24, did not contain documentation of a central registry finding.
6. During interviews, management acknowledged these background checks were the only documentation on file for each staff. The central registry finding was not obtained for all staff members within 30 days of employment.
Evidence:
1. The central registry finding in the record of Staff #8, date of employment 10/03/22, was dated 01/04/23.
2. The central registry finding in the record of Staff #13, date of employment 06/05/23, was dated 09/04/23.
3. The record of Staff #19, employed on 08/16/21, did not contain documentation of a central registry finding.
4. The central registry finding in the record of Staff #20, date of employment 10/03/22, was dated 01/04/23.
5. The record of Staff #23, employed on 03/26/24, did not contain documentation of a central registry finding.
6. During interviews, management acknowledged these background checks were the only documentation on file for each staff. The central registry finding was not obtained for all staff members within 30 days of employment.
Plan of Correction: Per the Center: "The violations written for Staff #8, #13, and #20 include files that were brought into compliance in 2022 and 2023. The management responsible for these violations has separated from the company.
Staff #23 has separated from the company.
Staff #19 now contain documentation of central registry finding.
Management will obtain central registry finding for each staff member within 30 days of employment."
Staff #23 has separated from the company.
Staff #19 now contain documentation of central registry finding.
Management will obtain central registry finding for each staff member within 30 days of employment."
Standard 8VAC20-780-160-A
(REPEAT VIOLATION/SYSTEMIC VIOLATION) Based on a review of 33 staff records and interviews, the center did not ensure that eleven staff members had a tuberculosis (TB) screening within the required timeframe.
Evidence:
1. The TB screening in the record of Staff #1, date of employment 01/15/24, was completed on 01/31/24.
2. The most recent TB screening in the record of Staff #2, date of employment 05/16/24, was completed on 06/04/24. A previous TB screening on file was completed on 03/01/24.
3. The most recent TB screening in the record of Staff #12, date of employment 08/14/23, was completed on 07/16/24. A previous TB screening on file was completed on 06/13/23.
4. The TB screening in the record of Staff #15, date of employment 03/08/24, was completed on 07/12/24.
5. The TB screening in the record of Staff #22, date of employment 01/14/24, was completed on 01/31/24.
6. The TB screening in the record of Staff #23, date of employment 03/26/24, was completed on 07/16/24.
7. The most recent TB screening in the record of Staff #26, date of employment 01/02/24, was completed on 07/16/24. A previous TB screening on file was completed on 01/31/24.
8. The most recent TB screening in the record of Staff #28, date of employment 01/29/24, was completed on 07/16/24. A previous TB screening on file was completed on 01/31/24.
9. The TB screening in the record of Staff #29, date of employment 01/28/24, was completed on 07/16/24.
10. The TB screening in the record of Staff #30, date of employment 04/15/24, was completed on 07/16/24.
11. The TB screening in the record of Staff #31, date of employment 04/15/24, was completed on 07/16/24.
12. During interviews, management acknowledged the TB screenings were not completed within the required timeframe for all staff.
Documentation of the screening shall 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 TB screening in the record of Staff #1, date of employment 01/15/24, was completed on 01/31/24.
2. The most recent TB screening in the record of Staff #2, date of employment 05/16/24, was completed on 06/04/24. A previous TB screening on file was completed on 03/01/24.
3. The most recent TB screening in the record of Staff #12, date of employment 08/14/23, was completed on 07/16/24. A previous TB screening on file was completed on 06/13/23.
4. The TB screening in the record of Staff #15, date of employment 03/08/24, was completed on 07/12/24.
5. The TB screening in the record of Staff #22, date of employment 01/14/24, was completed on 01/31/24.
6. The TB screening in the record of Staff #23, date of employment 03/26/24, was completed on 07/16/24.
7. The most recent TB screening in the record of Staff #26, date of employment 01/02/24, was completed on 07/16/24. A previous TB screening on file was completed on 01/31/24.
8. The most recent TB screening in the record of Staff #28, date of employment 01/29/24, was completed on 07/16/24. A previous TB screening on file was completed on 01/31/24.
9. The TB screening in the record of Staff #29, date of employment 01/28/24, was completed on 07/16/24.
10. The TB screening in the record of Staff #30, date of employment 04/15/24, was completed on 07/16/24.
11. The TB screening in the record of Staff #31, date of employment 04/15/24, was completed on 07/16/24.
12. During interviews, management acknowledged the TB screenings were not completed within the required timeframe for all staff.
Documentation of the screening shall 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.
Plan of Correction: Per the Center: "The 11 listed employee files, although missing the time frame requirement of within 30 days of employment and also prior to contact with children, all contained a completed TB screening at the time of inspection.
Management that was interviewed during the inspection visit was responsible for the internal audit and the subsequent completed screenings that brought the staff files into compliance with 8VAC20-780-(2)-160-A prior to the licensing visit where the time frame violations, (subsection 1 and 2) were noted here. Management will continue to maintain staff files in compliance.
Management that was responsible for the time frame violation has separated from the company."
Management that was interviewed during the inspection visit was responsible for the internal audit and the subsequent completed screenings that brought the staff files into compliance with 8VAC20-780-(2)-160-A prior to the licensing visit where the time frame violations, (subsection 1 and 2) were noted here. Management will continue to maintain staff files in compliance.
Management that was responsible for the time frame violation has separated from the company."
Standard 8VAC20-780-160-C
(REPEAT VIOLATION) Based on a review of 33 staff records and interviews, the center did not ensure that one staff member obtained and submitted the results of a follow-up tuberculosis (TB) screening at least every two years from the date of the initial screening or testing.
Evidence: The most recent TB screening in the record of Staff #4, date of employment 09/21/21, was completed on 01/31/24. The previous TB screening was completed on 01/14/22 and expired on 01/14/24. During interviews, management acknowledged the TB for Staff #4 was not obtained within the required timeframe.
Evidence: The most recent TB screening in the record of Staff #4, date of employment 09/21/21, was completed on 01/31/24. The previous TB screening was completed on 01/14/22 and expired on 01/14/24. During interviews, management acknowledged the TB for Staff #4 was not obtained within the required timeframe.
Plan of Correction: Per the Center: "The staff file contained a completed repeat TB screening at the time of inspection. The repeat test was however completed 17 days beyond when it should have been completed to maintain compliance with the 2 year interval.
Management responsible for this lack of timely repeat TB test has separated from the company.
Management interviewed at the time of inspection will continue to maintain timely intervals for repeat TB screening for staff."
Management responsible for this lack of timely repeat TB test has separated from the company.
Management interviewed at the time of inspection will continue to maintain timely intervals for repeat TB screening for staff."
Standard 8VAC20-780-240-A
(REPEAT VIOLATION/SYSTEMIC VIOLATION) Based on a review of 33 staff records and interviews, the center did not ensure that three staff members completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence:
1. Staff #7, date of employment 04/03/23, completed the Virginia Department of Education-sponsored orientation course on 07/19/24.
2. Staff #20, date of employment 10/03/22, completed the Virginia Department of Education-sponsored orientation course on 07/16/24.
3. The record of Staff #21, date of employment 02/19/24, did not contain documentation that the staff completed the Virginia Department of Education-sponsored orientation course. 4. During interview, management reported Staff #21 is working on the course.
Evidence:
1. Staff #7, date of employment 04/03/23, completed the Virginia Department of Education-sponsored orientation course on 07/19/24.
2. Staff #20, date of employment 10/03/22, completed the Virginia Department of Education-sponsored orientation course on 07/16/24.
3. The record of Staff #21, date of employment 02/19/24, did not contain documentation that the staff completed the Virginia Department of Education-sponsored orientation course. 4. During interview, management reported Staff #21 is working on the course.
Plan of Correction: Per the Center: "Management that was interviewed at the time of inspection was the person responsible for conducting the internal audit, and also the person responsible for immediately bringing the forms into compliance upon discovery. Management will continue to maintain staff files in compliance.
Staff #21 will complete the required orientation course by 9/30/2024.
Management responsible for the incomplete orientation separated from the company."
Staff #21 will complete the required orientation course by 9/30/2024.
Management responsible for the incomplete orientation separated from the company."
Standard 8VAC20-780-240-B
(REPEAT VIOLATION/SYSTEMIC VIOLATION) Based on a review of 33 staff records and interviews, the center did not ensure four staff members completed orientation training prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
Evidence:
1. The orientation training in the record of Staff #7, date of employment 04/03/23, was completed on 01/04/24.
2. The orientation training in the record of Staff #12, date of employment 08/14/23, was completed on 01/04/24.
3. The orientation training in the record of Staff #16, date of employment 12/04/23, was completed on 01/04/24.
4. The orientation training in the record of Staff #29, date of employment 01/28/24, was completed on 02/27/24.
5. During interviews, management reported the center did not have additional documentation to verify the orientation training was completed within the required timeframe.
Evidence:
1. The orientation training in the record of Staff #7, date of employment 04/03/23, was completed on 01/04/24.
2. The orientation training in the record of Staff #12, date of employment 08/14/23, was completed on 01/04/24.
3. The orientation training in the record of Staff #16, date of employment 12/04/23, was completed on 01/04/24.
4. The orientation training in the record of Staff #29, date of employment 01/28/24, was completed on 02/27/24.
5. During interviews, management reported the center did not have additional documentation to verify the orientation training was completed within the required timeframe.
Plan of Correction: Per the Center: "While not in compliance with the required time frame for completion, the four staff files did contain completed orientation.
The management responsible for the lack of compliance with completing orientation within 7 days of employment and also before working alone with children, has separated from the company.
Management interviewed at the time of inspection will comply with timely completion of orientation in compliance with standards."
The management responsible for the lack of compliance with completing orientation within 7 days of employment and also before working alone with children, has separated from the company.
Management interviewed at the time of inspection will comply with timely completion of orientation in compliance with standards."
Standard 8VAC20-780-240-E
(REPEAT VIOLATION) Based on a review of 33 staff records and interviews, the center did not ensure that two staff members completed orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care, within 30 days of the first day of employment.
Evidence:
1. The record of Staff #7, date of employment 04/03/23, contained documentation that the staff completed orientation training in first aid and CPR on 07/18/24.
2. The record of Staff #12, date of employment 08/14/23, contained documentation that the staff completed orientation training in first aid and CPR on 01/04/24.
3. During interview, management reported the center did not have documentation to verify Staff #7 and Staff #12 completed the training within 30 days of the first day of employment.
Evidence:
1. The record of Staff #7, date of employment 04/03/23, contained documentation that the staff completed orientation training in first aid and CPR on 07/18/24.
2. The record of Staff #12, date of employment 08/14/23, contained documentation that the staff completed orientation training in first aid and CPR on 01/04/24.
3. During interview, management reported the center did not have documentation to verify Staff #7 and Staff #12 completed the training within 30 days of the first day of employment.
Plan of Correction: Per the Center: "Management interviewed at the time of inspection is the person responsible for the internal audit and subsequent completion of required CPR and First Aid training for Staff #7. Management will continue to maintain compliance with CPR/First Aid training completion time frames.
Management responsible for the lack of timely completion of CPR/First Aid has separated from the company."
Management responsible for the lack of timely completion of CPR/First Aid has separated from the company."
Standard 8VAC20-780-245-A
Based on a review of 33 staff records and interviews, the center did not ensure that two staff members completed annually a minimum of 16 hours of training appropriate to the age of children in care.
Evidence:
1. The record of Staff #7, date of employment 04/03/23, contained 7 hours of annual training from 04/04/23 ? 04/03/24.
2. The record of Staff #13, date of employment 06/05/23, contained 6 hours of annual training from 06/06/23 ? 06/05/24.
3. During interviews, management reported this is the documentation that was obtained from each staff to date.
Evidence:
1. The record of Staff #7, date of employment 04/03/23, contained 7 hours of annual training from 04/04/23 ? 04/03/24.
2. The record of Staff #13, date of employment 06/05/23, contained 6 hours of annual training from 06/06/23 ? 06/05/24.
3. During interviews, management reported this is the documentation that was obtained from each staff to date.
Plan of Correction: Per the Center: "Staff #7, and #13 will have completed annual training hours as required in the standard by 9/30/24
Management responsible for the lack of documented training hours has separated from the company.
Management interviewed at the time of inspection will continue to maintain compliance with annual training hour documentation."
Management responsible for the lack of documented training hours has separated from the company.
Management interviewed at the time of inspection will continue to maintain compliance with annual training hour documentation."
Standard 8VAC20-780-270-A
(REPEAT VIOLATION/SYSTEMIC VIOLATION) Based on observations and interviews, the center did not ensure that areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable 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: During the walk-through of the facility on 07/29/24, the inspector observed four areas of chipped and peeling paint in the Pre-K 2 classroom. During interviews, management acknowledged the peeling paint was in areas accessible to the children in care.
Evidence: During the walk-through of the facility on 07/29/24, the inspector observed four areas of chipped and peeling paint in the Pre-K 2 classroom. During interviews, management acknowledged the peeling paint was in areas accessible to the children in care.
Plan of Correction: Per the Center: "The chipped and peeling paint in Pre-K 2 classroom has been repaired."
Standard 8VAC20-780-70
(REPEAT VIOLATION/SYSTEMIC VIOLATION) Based on a review of 33 staff records and interviews, the center did not ensure that four staff records contained the required information.
Evidence: 1. The references in the record of Staff #12, date of employment 08/14/23, were obtained on 07/18/24.
2. The references in the record of Staff #15, date of employment 03/08/24, were obtained on 07/11/24.
3. The record of Staff #23, date of employment 03/26/24, did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
4. The references in the record of Staff #30, date of employment 04/15/24, were obtained on 04/16/24.
5. During interviews, management acknowledged that the references were not all obtained prior to employment for all staff.
Each staff record shall contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
Evidence: 1. The references in the record of Staff #12, date of employment 08/14/23, were obtained on 07/18/24.
2. The references in the record of Staff #15, date of employment 03/08/24, were obtained on 07/11/24.
3. The record of Staff #23, date of employment 03/26/24, did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
4. The references in the record of Staff #30, date of employment 04/15/24, were obtained on 04/16/24.
5. During interviews, management acknowledged that the references were not all obtained prior to employment for all staff.
Each staff record shall contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
Plan of Correction: Per the Center: "The management interviewed at the time of inspection visit is the person responsible for internal audit that resulted in 3 of the 4 files being in compliance at the time of the visit. Management will continue to ensure staff files are compliant.
Staff #23 has separated from the company.
The management responsible for the files missing the required information has separated from the company."
Staff #23 has separated from the company.
The management responsible for the files missing the required information has separated from the company."