Inspection · 2024-08-29
Date
2024-08-29
Complaint Related
No
Licensing Inspector
Michelle Argenbright
(540) 848-4123
(540) 848-4123
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.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced, on-site renewal inspection was initiated on 08/29/2024 and completed on 09/06/2024 under the supervision of the Licensing Administrator. The on-site inspection began at 10:15 AM and ended at 2:30 PM. The inspector reviewed compliance in the areas listed above. There were 79 children present and 15 staff. The inspector reviewed seven children?s records and seven staff records were reviewed on-site. 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 09/23/2024. A POC submitted after this date will not appear on the public website.
Violations
16Standard 22.1-289.035-B-3
Based on record review and interview, the center failed to request a search of the central registry prior to employment of a new staff.
Evidence:
Staff 6, employed for a period of almost two months, was working alone in a classroom prior to the center requesting a search of the central registry.
Evidence:
Staff 6, employed for a period of almost two months, was working alone in a classroom prior to the center requesting a search of the central registry.
Plan of Correction: We had staff 6 complete the correct background form and sent it to the central registry. Staff 6 will not be in classrooms unsupervised until this comes back clear.
Standard 8VAC20-780-130-E
Based on interview and document review, the center failed to obtain documentation of
additional immunizations once every six months for children under the age of two years.
Evidence:
1. A period of over nine months lapsed before the center obtained documentation
of immunizations for child 6, less than two years of age.
additional immunizations once every six months for children under the age of two years.
Evidence:
1. A period of over nine months lapsed before the center obtained documentation
of immunizations for child 6, less than two years of age.
Plan of Correction: The owner, Director and assistant Director will be reviewing children?s files to be sure that even when foster placement changes, that we have updated medical documents per licensing guidelines.
Standard 8VAC20-780-270-A
Based on observation, the center failed to ensure areas and equipment of the center were maintained in a clean, safe and operable condition.
Evidence:
There were various areas of chipping paint and/or drywall thought the facility and the finish on multiple changing tables.
Evidence:
There were various areas of chipping paint and/or drywall thought the facility and the finish on multiple changing tables.
Plan of Correction: The classroom was completely repainted and is now upgraded with all new things.
Standard 8VAC20-780-280-B
REPEAT VIOLATION, SYSTEMIC DEFICIENCY Based on observation, the center failed to ensure hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children.
Evidence:
A storage closet, five classrooms, and four children's restrooms contained multiple unlocked hazardous substances.
Evidence:
A storage closet, five classrooms, and four children's restrooms contained multiple unlocked hazardous substances.
Plan of Correction: The Director will ensure that all classrooms are equipped with lock boxes for all cleaning materials. The assistant Director will conduct daily classroom inspections to ensure all safety guidelines are being met.
Standard 8VAC20-780-340-A
REPEAT VIOLATION Based on interviews, the center failed to ensure staff supervising children always provide care, protection, and guidance.
Evidence:
A three-year-old child was observed walking in the hall unsupervised near the kitchen. There were no staff present in the kitchen and the hallway door to the kitchen was open. A large pot containing boiling water with broccoli and a large pot containing a simmering substance were on the front burners of stove top.
Evidence:
A three-year-old child was observed walking in the hall unsupervised near the kitchen. There were no staff present in the kitchen and the hallway door to the kitchen was open. A large pot containing boiling water with broccoli and a large pot containing a simmering substance were on the front burners of stove top.
Plan of Correction: All children will be monitored by a staff member when leaving the classroom. The Director will ensure that all kitchen doors will always be closed, and the stovetop will be turned off when the kitchen staff is not present.
Standard 8VAC20-780-340-D
Based on observation, interview, and record review, the center failed to ensure in each grouping of children at least one staff member who meets the qualifications of a program leader or program director is regularly present.
Evidence:
Staff in the transition room did not meet the qualifications of a program leader or program director.
Evidence:
Staff in the transition room did not meet the qualifications of a program leader or program director.
Plan of Correction: We misunderstood that all 3 requirements of being a ?lead? must be established before a teacher can be left alone with children. We have reestablished our new hire paperwork to include this regulation. The Director will oversee staff files to ensure all qualifications have been met before a teacher can qualify as a lead.
Standard 8VAC20-780-340-F
Based on observation, the center failed to ensure children under the age of 10 are always
within actual sight and sound supervision of staff.
Evidence:
1. Staff 4 left four children unsupervised in the Junior PreK classroom, the youngest child was two-years-old and a three-year old child was observed walking unsupervised in the hallway. One child was observed standing on the edge of the top of a table.
2. Staff 8, PreK classroom youngest age three, left eight children alone in the classroom.
within actual sight and sound supervision of staff.
Evidence:
1. Staff 4 left four children unsupervised in the Junior PreK classroom, the youngest child was two-years-old and a three-year old child was observed walking unsupervised in the hallway. One child was observed standing on the edge of the top of a table.
2. Staff 8, PreK classroom youngest age three, left eight children alone in the classroom.
Plan of Correction: 1) Children must always remain with a staff member and within sight and sound. When the Junior Pre-K classroom needs to ensure handwashing, the Director will come into the classroom to assist the needs of the teacher.
2) The Director will remind staff in Junior Pre-K to either use the intercom system or simply holler to the office when another set of hands is needed.
2) The Director will remind staff in Junior Pre-K to either use the intercom system or simply holler to the office when another set of hands is needed.
Standard 8VAC20-780-350-B-2
Based on observation, the center failed to ensure the staff-to-children ratio for 16 months to 24 months was one staff to five children whenever children are in care.
Evidence:
In the 2's classroom, the youngest child (child 4) turns two in three months. The ratio was one staff to eight children.
Evidence:
In the 2's classroom, the youngest child (child 4) turns two in three months. The ratio was one staff to eight children.
Plan of Correction: The Director will ensure all ASQ?s are submitted, complete with all answers and dated accurately.
Standard 8VAC20-780-350-B-3
Based on observation, the center failed to ensure the staff-to-children ratio for two-year-old's is one staff to eight children whenever children are in care.
Evidence:
In the preschool classroom, the youngest child was two-years-old. There was one staff to 10 children.
Evidence:
In the preschool classroom, the youngest child was two-years-old. There was one staff to 10 children.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-350-Q
SYSTEMIC DEFICIENCY Based on interview and document review, the center chose to assign a child to a different age group without a written assessment by the program director and program leader.
Evidence:
1. The records for child 3, 4, 5, and 7 contained documentation requesting parental
permission to move the child to the next developmental class based on completion
of the Ages and Stages Questionnaire used to assess development; however, none
of these records contained the written assessment, nor could the written
assessments be provided by the center.
Evidence:
1. The records for child 3, 4, 5, and 7 contained documentation requesting parental
permission to move the child to the next developmental class based on completion
of the Ages and Stages Questionnaire used to assess development; however, none
of these records contained the written assessment, nor could the written
assessments be provided by the center.
Plan of Correction: The Director will ensure all ASQ?s are submitted, complete with all answers and dated accurately. The children who these documents are completed on must meet all the milestones before this document can be signed off for the child to be placed in an older age group than their age.
Standard 8VAC20-780-40-M
Based on observation and interview, the center failed to maintain, in a way that is accessible to all staff who work with children, a current written, confidential list of all children's allergies, sensitivities, and dietary restrictions documented in the allergy plan in each room or area where children are present.
Evidence:
The food allergies and sensitivities were posted in the transition room on the wall for anyone to see.
Evidence:
The food allergies and sensitivities were posted in the transition room on the wall for anyone to see.
Plan of Correction: The assistant Director has been going through all classrooms to ensure allergies, sensitivities and dietary restrictions are posted for anyone who is in the classroom; however, they now have cover sheets to ensure confidentiality.
Standard 8VAC20-780-500-B
Based on observation, the center failed to dispose diapers in a leakproof or plastic-lined storage system that is either foot-operated or used in such a way that neither the staff member's hand nor the soiled diaper touches an exterior surface of the storage system during disposal.
Evidence:
The foot-operated trash can staff use to dispose of diapers was not working in the Toddler 2's room.
Evidence:
The foot-operated trash can staff use to dispose of diapers was not working in the Toddler 2's room.
Plan of Correction: The owner will be sure to double check all trash cans upon opening of the facility, to ensure they are all operating correctly.
Standard 8VAC20-780-520-A
Based on observation, the center failed to ensure all nonprescription drugs and over-the-counter skin products shall be used in accordance with the manufacturer's recommendations and shall not be kept or used beyond the expiration date of the product.
Evidence:
One diaper ointment was found to be expired.
Evidence:
One diaper ointment was found to be expired.
Plan of Correction: The assistant Director has been going through all classrooms to ensure all medications and diaper creams are within current date.
Standard 8VAC20-780-530-A
Based on interview and record review, the center failed to ensure at least one CPR & first aid certified staff is present in each classroom at all times where children are present.
Evidence:
One classrooms did not have staff that has completed the hands on portion of CPR training.
Evidence:
One classrooms did not have staff that has completed the hands on portion of CPR training.
Plan of Correction: We will communicate with sister agency that provides training to some of our employees to ensure all trainings are correct and staff 6 is now signed up for the hands-on training October 19th.
Standard 8VAC20-780-550-P
Based on record review, the center failed to maintain a written record of children?s serious and minor injuries in which entries are made the day of occurrence and that have all the required information.
Evidence:
An injury report dated 8/28/24 did not contain the time parents were notified.
Evidence:
An injury report dated 8/28/24 did not contain the time parents were notified.
Plan of Correction: The Director will ensure all injury logs are completed in full and accurate with all details required. The information require on the injury logs has been reviewed with all staff by the Director, so everyone is aware how important all the details are.
Standard 8VAC20-780-60-A
Based on interview and document review, the center failed to maintain a separate
record for each child enrolled that contained the required information.
Evidence:
1. The records for child 1, 2, 3, 4, 5, and 7 did not contain all required information.
record for each child enrolled that contained the required information.
Evidence:
1. The records for child 1, 2, 3, 4, 5, and 7 did not contain all required information.
Plan of Correction: The owner, Director and assistant Director will be reviewing children?s files who are currently enrolled to ensure they are completed in full. Files for newly enrolled children will be reviewed before first day?s attendance.