Inspection · 2022-03-28
(804) 629-7519
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 (8VAC20-770)
22.1 Early Childhood Care and Education
Inspector Notes
This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, interviews and a in-person tour of the program A monitoring inspection was initiated on 3/25/22 and concluded on 3/28/22. The provider was contacted by telephone to initiate the inspection. There were 52 children present and 13 staff. The inspector emailed the director/provider a list of items required to complete the inspection. The Inspector reviewed 5 children?s records and 9 staff records, along with any requested program records submitted by the facility to determine if required documentation was complete. 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.
Violations
14Evidence:
1. The record for Staff #1 (DOH: 02/07/22), working during the inspection, did not contain documentation of a completed national criminal history record check (finger printing).
2. The record for Staff #6 (DOH: 02/22/22), working during the inspection, did not contain documentation of a completed national criminal history record check (finger printing).
3. Staff #1, Program Director, confirmed that she had not received the results of the finger print background check (finger printing) for staff #1 and staff #6.
2. A REQUEST FOR BACKGROUND PORTABILITY: Central Registry and Criminal was sent via email on 2/4/22. Brilliant Beginnings received a REQUEST FOR BACKGROUND PORTABILITY: Central Registry and Criminal check that included Staff #6?s name. Being unfamiliar with the process, after receiving this form from the backgrounds department, it was assumed this was the correct information needed in order for Staff #6 to begin employment. It was not until our licensing inspection that we were informed the information we received from the backgrounds department regarding Staff #6 was incomplete. On March 30, 2022, Brilliant Beginnings received a response from the Office of Background Investigation-Criminal Background Unit deeming Staff #6 eligible as an employee.
Evidence:
1. The record for staff #4 (date of hire 3/7/22) did not contain documentation of a completed criminal record check and sex offender registry check from Nevada. The sworn statement indicated staff #4 had previously lived in Nevada within the last 5 years.
2. The record for staff #5 (date of hire 11/9/21) did not contain documentation of a completed criminal record check, search of the central registry finding, and sex offender registry check from Pennsylvania. The sworn statement indicated staff #4 had previously lived in Pennsylvania within the last 5 years.
3. Staff #1 (Program Director) confirmed the criminal record check and a sex offender registry check from the State of Nevada (staff #4) and Pennsylvania (staff #5) were received prior to start of employment. In addition the completed search of the child abuse and neglect registry or equivalent registry from Pennsylvania for staff #5 was received within 45 days of hire.
2. Brilliant Beginnings provided our Licensing inspector, Christopher Robinson a completed Criminal History Check for Pennsylvania and a Sex Offender Registry Check for Staff # 5 on 3/28/22 as he requested. Brilliant Beginnings failed to provide a completed Central Registry Check for Staff #5. Staff #5 has been placed on administrative leave until we send/receive a Sex Offender Registry Check from Pennsylvania.
Evidence:
1. The record for staff #1 (DOH: 3/26/22), did not contain documentation of a completed search of the central registry finding.
2. The record for staff #3 (DOH: 03/04/2022), did not contain documentation of a completed search of the central registry finding.
3. The record for staff #5 (DOH: 11/09/2021), did not contain documentation of a completed search of the central registry finding.
4. The record for staff #6 (DOH: 02/02/22), did not contain documentation of a completed search of the central registry finding.
5. The record for staff #7 (DOH: 09/28/2021), did not contain documentation of a completed search of the central registry finding.
6. The record for staff #8 (DOH: 12/08/2021), did not contain documentation of a completed search of the central registry finding.
7. Staff #1 (Program Director), reviewed the records and confirmed that the search of the central registry finding has not been received for nay of the staff listed above..
Evidence:
1. The record for child #5 contained an immunization record with no No physician signature.
2. Staff #1 (Program Director) confirmed no physician signature to the immunization record.
Evidence:
1. The record for staff #1 (DOH: 02/08/2022) contained a TB screening that was dated 06/08/2021.
2. The record for staff #3, (DOH: 03/04/2022),contained a TB screening that was dated 08/24/2021.
3. Staff #1 (Program Director) confirmed that the TB screening received for both staff was completed more than 30 days prior to employment.
2. Brilliant Beginnings obtained a Tuberculosis screening for Staff # 3 on 3/30/22.
Evidence:
1. The exterior doors for the toddler and two?s classroom on the small playground had peeling paint in reach of children.
2. The play structure on the large playground had an approximate 10 inch crack to the plastic exterior posing a possible injury to a child.
3. Staff #1 (Program Director), confirmed the areas listed above were not maintained in a safe and operable condition.
2. There is an existing work order for the playground structure scheduled to be completed on or before June 2022.
Evidence:
1. In the infant room, an uncovered deodorizing aerosol bottle was on top of the refrigerator.
2.In the toddler room, an open box of baking soda was on the floor of an unlocked closet within reach of the children.
3. In the three year old classroom, there were two unlabeled cleaning substances in bottles that were in an unlocked cabinet.
4. In the school age room, two unlabeled cleaning bottles, a container of disinfectant wipes, and disinfectant spray that were in an unlocked cabinet accessible to children.
5. In the school age room and two year old room, scented gel deodorizer in the room were unlocked and accessible to children.
6. Staff #1 (Program Director), confirmed the hazardous substances listed above were not stored in a locked place using a safe locking method that prevents access by children.
2. Staff in the toddler room failed to ensure hazardous substances were kept in a locked place using a safe locking method that prevents the access by children. Toddler staff who were present at the time of the violation, including the Director received a First Written Write-up. Staff were also mandated to complete and submit a training certificate for Green Cleaning, Sanitizing, and Disinfecting: A curriculum for ECE. Staff were informed that baking soda needed to be kept in a locked cabinet when not in use during a training on 4/4/22.
3. Staff in the three-year old classroom failed to ensure hazardous substances were kept in a locked place using a safe locking method that prevents the access by children. Preschool staff who were present at the time of the violation, including the Director received a First Written Write-Up. Staff were also mandated to complete and submit a training certificate for Green Cleaning, Sanitizing, and Disinfecting: A curriculum for ECE. Staff were trained on how to properly label bottles containing soap and water and sanitizing solution on 4/4/22.
4. Staff in the school-age room failed to ensure hazardous substances were kept in a locked place using a safe locking method that prevents access by children. School-age staff received a First Written Write-Up and were mandated to complete and submit a training certificate for PYD Foundations: Safety and Wellness.
5. Staff of the School-age and Two-year-old room failed to ensure hazardous substances were kept in a locked place using a safe locking method that prevents access by children. Staff received a First Written Write-Up. Staff were also mandated to submit a training certificate for Green Cleaning, Sanitizing, and Disinfecting: A curriculum for ECE. Staff were informed that cleaning supplies must be kept out of reach of children during a training held on 4/4/22.
Evidence:
1. In the three year old classroom, there were two unlabeled bottles containing a blue liquid in the cabinet over the sink.
2. In the school age classroom, there were two unlabeled bottles containing a blue liquid in the cabinet over the sink.
3. Staff #1 (Program Director) confirmed that the unlabeled bottles contained a cleaning substance and were not in the original containers.
2. Staff in the school-age room were reminded that all soap and water bottles must be labeled with their contents
Evidence:
1. In the Preschool (3's) classroom there was an unlocked closet which contained a purse belonging to staff #2. The purse was open and contained medication.
2. Both Staff #1 and Staff #2 confirmed and observed that the medication was not locked and accessible to the children.
Evidence:
1. On the large playground, there were tears and holes to the resilient surfacing (pour-n-play) which compromised its integrity.
2. Staff #1 (Program Director), confirmed the surfacing did not comply with safety standards.
Evidence:
1. In the infant room, the storage system used for disposing of diapers was not of a design of hands free operation.
2. Staff members in the infant room confirmed that they had used their hands to open the storage system to dispose of soiled diapers.
Evidence:
1. The medication authorization form for child #7 did not contain a parent signature to authorize the administration of medication.
2. The medication authorization form for child #8 did not contain a parent signature to authorize the administration of medication
3. Staff #1 (Program Director) confirmed that parent authorization to administer medication was not obtained for child #7 and child #8.
2. As of 4/5/22, Brilliant Beginnings received a parent signature authorizing administration of medication for child #8.
Evidence:
1. The medication (EpiPen) for Child #6, currently at the center for care, was not maintained in the original container with labeled directions attached.
2. Staff #1 (Program Director) confirmed the medication for child #6 was not maintained in its original container with the direction label attached.
Evidence:
1. The van used for transporting the children daily to and from local schools had an expired Department of Motor Vehicle registration. The registration expired July 2021.
2. Staff #1 (Program Director) confirmed the vehicle?s registration was expired and not in compliance with DVM safety standards.