Inspection · 2023-05-02
Date
2023-05-02
Complaint Related
No
Licensing Inspector
Diana DeSilva
(571) 596-3656
(571) 596-3656
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 (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 conducted today. 34 children with 5 staff were onsite today. All occupied and unoccupied classrooms were observed today along with the playground, indoor gross motor room and after care room. All medications onsite were reviewed. All areas of the Standards were reviewed. The children were eating lunch at the beginning of the inspection and were observed washing hands and transitioning to nap time. Staff rotated to allow for staff breaks. Some staff were observed assisting children to sleep by gently patting their backs and encouraging them to nap. A total of 5 children's records and 1 new staff record was reviewed. Due to staff coverage, additional recordation was not reviewed due to difficulty accessing the documents. This inspection began at approximately 12:15pm and ended at approximately 2pm. Please email me at: lisa.hudson@doe.virginia.gov with any questions.
Violations
12Standard 8VAC20-770-60-C-2
Based on staff record review, one background check was not obtained within 30 days of hire.
Evidence:
Staff #2 was hired on 03/06/2023. Results from a Central Registry search was not found.
Evidence:
Staff #2 was hired on 03/06/2023. Results from a Central Registry search was not found.
Plan of Correction: Staff #2? s start date was 3/16/2023,
please see attached CPS filing.
please see attached CPS filing.
Standard 8VAC20-780-140-A
Based on child record review, a physical examination was not obtained within 30 days of their start date for 1 child.
Evidence:
Child #5 started on 01/04/2023. A physical examination was not found for this child
Evidence:
Child #5 started on 01/04/2023. A physical examination was not found for this child
Plan of Correction: The physical examination form has
been obtained and all requirements
have been completed.
been obtained and all requirements
have been completed.
Standard 8VAC20-780-150-A
Based on child record review, the current form required by the Virginia Department of Health or a physician's form that includes all information on the Virginia Department of Health form was not used to report immunizations received and the results of the required physical examination.
Evidence:
1.Child #4?s physical exam form and immunization form do not include all required information.
2.A statement Child #4 and #5 has been adequately immunized was not found.
3.Both the physical exam form and the immunization form for Child #4 was not signed by a physician.
4.Child #5?s immunization form was not signed by the physician.
Evidence:
1.Child #4?s physical exam form and immunization form do not include all required information.
2.A statement Child #4 and #5 has been adequately immunized was not found.
3.Both the physical exam form and the immunization form for Child #4 was not signed by a physician.
4.Child #5?s immunization form was not signed by the physician.
Plan of Correction: 1. All requirements have been
completed.
The physical exam and immunization
forms have been sent to the parents
for completion and for signatures
completed.
The physical exam and immunization
forms have been sent to the parents
for completion and for signatures
Standard 8VAC20-780-160-A
Based on staff record review, a TB health screening was not obtained prior to hire.
Evidence:
Staff #2 was hired on 03/06/2023. The TB risk assessment is dated 03/08/2023.
Evidence:
Staff #2 was hired on 03/06/2023. The TB risk assessment is dated 03/08/2023.
Plan of Correction: This was an error. Staff #2?s start date
was 3/16/2023/ We fixed this error in
her file and changed the start date.
was 3/16/2023/ We fixed this error in
her file and changed the start date.
Standard 8VAC20-780-240-B
Based on review of staff records, orientation training for 1 staff was not completed within the first 7 days of starting their responsibilities.
Evidence:
1.Staff #2 was hired on 03/06/2023.
2.The orientation training maintained in the staff record did not include training on shaking baby syndrome, abusive head trauma, preventing and recognizing allergic reactions and playground safety procedures.
Evidence:
1.Staff #2 was hired on 03/06/2023.
2.The orientation training maintained in the staff record did not include training on shaking baby syndrome, abusive head trauma, preventing and recognizing allergic reactions and playground safety procedures.
Plan of Correction: Staff #2 is finishing the training and it
will be completed by tomorrow. The
certificate will be sent to you as soon
the training is completed
will be completed by tomorrow. The
certificate will be sent to you as soon
the training is completed
Standard 8VAC20-780-245-J-3
Based on review of onsite medications, one child who has an emergency medication was not in the presence of a staff who has completed the appropriate medication training.
Evidence:
1.An emergency seizure medication was found for Child #1.
2.This medication is required to be administered rectally.
3.Staff #3 stated that the additional rectal medication training has not been completed by any staff present today.
Evidence:
1.An emergency seizure medication was found for Child #1.
2.This medication is required to be administered rectally.
3.Staff #3 stated that the additional rectal medication training has not been completed by any staff present today.
Plan of Correction: The required training has been
completed by the necessary staff.
Please see the attachment.
completed by the necessary staff.
Please see the attachment.
Standard 8VAC20-780-270-A
Based on observation of the center, one area of the building was not maintained in a safe and operable manner.
Evidence:
The top drawer of the changing table located in the bathroom near the aftercare classroom was broken and hanging off the frame.
Evidence:
The top drawer of the changing table located in the bathroom near the aftercare classroom was broken and hanging off the frame.
Plan of Correction: We removed the drawer, and it is no
longer a hazard.
longer a hazard.
Standard 8VAC20-780-280-B
Based on observation of the center, hazardous substances were found in unlocked areas.
Evidence:
1.The storage closet located in the bathroom near the aftercare classroom was unlocked and contained cleaning agents.
2.The storage closet located in classroom #1 was unlocked and contained cleaning agents.
Evidence:
1.The storage closet located in the bathroom near the aftercare classroom was unlocked and contained cleaning agents.
2.The storage closet located in classroom #1 was unlocked and contained cleaning agents.
Plan of Correction: 1. We put up a sign in Spanish and
English to lock the door after each
use.
2. We put up a sign in Spanish and
English to lock the door after each
use. Each morning before the start of
school, each opening staff will be
checking it regularly.
English to lock the door after each
use.
2. We put up a sign in Spanish and
English to lock the door after each
use. Each morning before the start of
school, each opening staff will be
checking it regularly.
Standard 8VAC20-780-380-A
Based on observation of the center a daily schedule of activities was not posted.
Evidence:
A daily schedule of activities was not posted in all 3 classrooms.
Evidence:
A daily schedule of activities was not posted in all 3 classrooms.
Plan of Correction: A daily schedule of activities has been
posted in all 3 classrooms
posted in all 3 classrooms
Standard 8VAC20-780-40-L
Based on a staff statement, the center failed to inform 1 staff of children?s allergies.
Evidence:
1.Staff are required to know which children have food allergies.
2. Staff are trained to recognize allergic reactions.
3. Staff #1 was the only staff in Classroom 1.
4. When asked, Staff #1 stated ?There are no children with food allergies in this class.?
5. Staff #1 was unable to locate the list of allergies for Classroom 1.
3. After reviewing the list of food allergies for the center, Classroom 1 has one child with a nut allergy.
Evidence:
1.Staff are required to know which children have food allergies.
2. Staff are trained to recognize allergic reactions.
3. Staff #1 was the only staff in Classroom 1.
4. When asked, Staff #1 stated ?There are no children with food allergies in this class.?
5. Staff #1 was unable to locate the list of allergies for Classroom 1.
3. After reviewing the list of food allergies for the center, Classroom 1 has one child with a nut allergy.
Plan of Correction: We had an emergency staff meeting
in which we talked all about the
students with allergies and the
necessary actions to be taken.
Additionally, allergy signs and lists of
students with allergies have been
posted in all 3 classrooms. Please see
the attachment.
in which we talked all about the
students with allergies and the
necessary actions to be taken.
Additionally, allergy signs and lists of
students with allergies have been
posted in all 3 classrooms. Please see
the attachment.
Standard 8VAC20-780-510-E
Based on review of onsite medication, the center failed to follow their own medication policy.
Evidence:
1.A signed physician medication authorization was not found for 2 emergency medications for Child #1.
2.A signed physician medication authorization was not found for Child #2?s emergency medication.
Evidence:
1.A signed physician medication authorization was not found for 2 emergency medications for Child #1.
2.A signed physician medication authorization was not found for Child #2?s emergency medication.
Plan of Correction: We have given the physician
medication forms for the respective
medications to the parents and to the
parents who need to obtain the
signatures.
medication forms for the respective
medications to the parents and to the
parents who need to obtain the
signatures.
Standard 8VAC20-780-60-A
Based on child record review, children?s records were found incomplete.
Evidence:
1.A start date for Child #1 was not found in their record.
2.The phone numbers and addresses for Child #3?s emergency contacts were not found in their record.
3.Acknowledgement that the parent handbook was provided that included policies on communicable diseases and requirements to pick a child up ill was not found in Child #3?s record.
4.Child #1 has a diagnosed food allergy. A signed physician allergy action plan was not found in their record.
Evidence:
1.A start date for Child #1 was not found in their record.
2.The phone numbers and addresses for Child #3?s emergency contacts were not found in their record.
3.Acknowledgement that the parent handbook was provided that included policies on communicable diseases and requirements to pick a child up ill was not found in Child #3?s record.
4.Child #1 has a diagnosed food allergy. A signed physician allergy action plan was not found in their record.
Plan of Correction: All requirements have been
completed
completed