Inspection · 2022-03-30
Date
2022-03-30
Complaint Related
No
Licensing Inspector
Maria Robles-Lopez
(703) 397-3827
(703) 397-3827
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 PROGRAMS.
8VAC20-780 Special care provisions and emergencies.
8VAC20-820 THE LICENSE.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Early Childhood Care and Education
Inspector Notes
A monitoring inspection was conducted on 03/30/2021 between the hours of approximately 12:30 pm to 1:45 pm. There were 25 children present, ranging in ages from 3 to 5 years, with 4 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 3 child records and 3 staff records were reviewed.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. If you have any questions regarding this inspection, please contact the Licensing Inspector, Maria Robles at maria.robles@doe.virginia.gov.
Violations
13Standard 22.1-289.035-B-2
Based on record review, the center did not ensure to obtain fingerprint-based criminal history check determination letter prior to first day of employment for one staff person.
Evidence:
1) On the date of inspection, no fingerprint-based criminal history check determination letter was available to review in the record for Staff #3 (start date 08/23/2021). At a later date a CFNC representative provided the documentation, however, it was dated 10/12/2021.
Evidence:
1) On the date of inspection, no fingerprint-based criminal history check determination letter was available to review in the record for Staff #3 (start date 08/23/2021). At a later date a CFNC representative provided the documentation, however, it was dated 10/12/2021.
Plan of Correction: Fingerprints is in staff's file.
Standard 22.1-289.035-B-4
Based on record review, it was determined that the center did not ensure that employees that had lived out of the state of VA within the last 5 years have in their files the results of an out-of-state criminal history name check and out-of-state Sex Offender Registry search request prior to the first day of employment; and the results of an out-of-state Central Registry search request within 30 days of employment.
Evidence:
1) The record for Staff #3 (start date 08/23/2021) did not contain documentation of an out-of-state criminal history name check, out-of-state Sex Offender Registry search request and out-of-state Central Registry search request. Staff #3 had declared in their sworn statement having lived out of the state of VA within the last 5 years before employment.
Evidence:
1) The record for Staff #3 (start date 08/23/2021) did not contain documentation of an out-of-state criminal history name check, out-of-state Sex Offender Registry search request and out-of-state Central Registry search request. Staff #3 had declared in their sworn statement having lived out of the state of VA within the last 5 years before employment.
Plan of Correction: We are currently working to get the out-of-state request.
Standard 8VAC20-770-60-B
Based on record review, the center did not ensure to obtain a completed Sworn Statement prior to first day of employment.
Evidence:
1) On the date of inspection, no Sworn Statement was available to review in the record for Staff #3 (start date 08/23/2021). At a later date a CFNC representative provided the documentation, however, it was dated 04/01/2022.
Evidence:
1) On the date of inspection, no Sworn Statement was available to review in the record for Staff #3 (start date 08/23/2021). At a later date a CFNC representative provided the documentation, however, it was dated 04/01/2022.
Plan of Correction: Completed on 04/01/2022.
Standard 8VAC20-770-60-C-2
Based on record review, it was determined that the center did not ensure that Central Registry search results were obtained by the end of the 30th day of employment.
Evidence:
1) On the date of inspection, no Central Registry search results were available to review in the record for Staff #3 (start date 08/23/2021). At a later date a CFNC representative provided the documentation, however, it was dated 10/06/2021.
Evidence:
1) On the date of inspection, no Central Registry search results were available to review in the record for Staff #3 (start date 08/23/2021). At a later date a CFNC representative provided the documentation, however, it was dated 10/06/2021.
Plan of Correction: Central Registry is in staff's file.
Standard 8VAC20-780-260-A
Based on observation and interview, an annual fire inspection report from the appropriate fire official having jurisdiction was not available for review.
Evidence:
1) At the time of inspection, an annual fire inspection report was not available for review on the center. 2) Staff at the center did not have a copy of the fire inspection report.
Evidence:
1) At the time of inspection, an annual fire inspection report was not available for review on the center. 2) Staff at the center did not have a copy of the fire inspection report.
Plan of Correction: A copy of the fire inspection report was later provided to the inspector by a representative of CFNC.
Standard 8VAC20-780-330-B
Based on observation, resilient surfacing in the playground did not comply with minimum safety standards.
Evidence:
1) On the date of inspection, there was not enough resilient surfacing remaining on the playground. Dirt and ground was able to be seen from where the resilient surfacing has been kicked out, especially on the landing zones of the slides.
Evidence:
1) On the date of inspection, there was not enough resilient surfacing remaining on the playground. Dirt and ground was able to be seen from where the resilient surfacing has been kicked out, especially on the landing zones of the slides.
Plan of Correction: We contacted the landscaping vendor to deliver mulch.
Standard 8VAC20-780-420-E-3
Based on record review, Staff did not request at least annually parent confirmation that the required information in the child's record is up to date.
Evidence:
1) The most recent update in the record for Child #1 was dated 08/11/2020. The most recent update in the record for Child #2 was dated 05/25/2020.
Evidence:
1) The most recent update in the record for Child #1 was dated 08/11/2020. The most recent update in the record for Child #2 was dated 05/25/2020.
Plan of Correction: We updated students records.
Standard 8VAC20-780-510-I
Based on medication and documentation review, it was determined that medication administration was
performed by a staff member who has not satisfactorily completed a training program for this purpose.
Evidence:
1) On the date of inspection, one medication for Child #4 was available in the center. 2) According to the medication log for the Green Room, this medication had been administered at least 6 times by Staff #3. No documentation was available in the center of a MAT certification for Staff #3. The inspector requested to a representative of the CFNC that documentation of the MAT certification for Staff #3 to be provided electronically but it was not provided.
performed by a staff member who has not satisfactorily completed a training program for this purpose.
Evidence:
1) On the date of inspection, one medication for Child #4 was available in the center. 2) According to the medication log for the Green Room, this medication had been administered at least 6 times by Staff #3. No documentation was available in the center of a MAT certification for Staff #3. The inspector requested to a representative of the CFNC that documentation of the MAT certification for Staff #3 to be provided electronically but it was not provided.
Plan of Correction: The Program director met with staff to go over medication. MAT certification is in process to be taken by staff.
Standard 8VAC20-780-510-L
Based on observation, medication was not kept in a locked place using a safe locking method that prevents access by children.
Evidence:
1) On the date of inspection, prescription medication for Child #4 was located in a backpack used to keep the first aid supplies for the Green Room. The medication was in a plastic bag inside the backpack with no locking method on the bag nor the backpack to prevent access by children.
Evidence:
1) On the date of inspection, prescription medication for Child #4 was located in a backpack used to keep the first aid supplies for the Green Room. The medication was in a plastic bag inside the backpack with no locking method on the bag nor the backpack to prevent access by children.
Plan of Correction: We purchased a locked safety bag and delivered to class
Standard 8VAC20-780-550-C
Based on observation and interview, emergency evacuation maps were not posted in a location conspicuous to staff and children on each floor.
Evidence:
1) On the date of inspection, emergency evacuation maps were not posted on neither the Green Room nor the Orange Room. 2) Teachers of each classroom stated that they did not have maps posted.
Evidence:
1) On the date of inspection, emergency evacuation maps were not posted on neither the Green Room nor the Orange Room. 2) Teachers of each classroom stated that they did not have maps posted.
Plan of Correction: Teachers were provided with the evacuation plan that we update every school year.
Standard 8VAC20-780-60-A
Based on record review, children's records did not contain all required information.
Evidence:
1) The record for Child #1 did not contain the work phone number and place of employment of one parent who has custody, address of two designated people to call in an emergency if a parent cannot be reached. The records for Child #2 and Child #3 did not contain the first date of attendance.
Evidence:
1) The record for Child #1 did not contain the work phone number and place of employment of one parent who has custody, address of two designated people to call in an emergency if a parent cannot be reached. The records for Child #2 and Child #3 did not contain the first date of attendance.
Plan of Correction: Corrections were made immediately.
Standard 8VAC20-780-70
Based on record review, staff records did not contain all required information.
Evidence:
1) The record for Staff #3 did not contain documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position.
Evidence:
1) The record for Staff #3 did not contain documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position.
Plan of Correction: All documents are in the staff's file.
Standard 8VAC20-820-120-E-2
Based on review of required posted documents, the center did not ensure that all required documents related to the terms of the license were posted on the premises of the program.
Evidence:
1) On the date of inspection, the findings of the most recent inspection of the facility (10/06/2021) were not posted. The most recent inspection report findings posted on the Green Room were dated 10/17/2019. There was no inspection report posted on the Orange Room.
Evidence:
1) On the date of inspection, the findings of the most recent inspection of the facility (10/06/2021) were not posted. The most recent inspection report findings posted on the Green Room were dated 10/17/2019. There was no inspection report posted on the Orange Room.
Plan of Correction: We were not aware that the latest inspection reports had to be posted. We will post this current on the board for the public to view.