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Virginia Commonwealth University Health System Authority -N Deck

Inspection · 2021-12-28

Date
2021-12-28
Complaint Related
No
Licensing Inspector
Lauren Bickford
(540) 280-0742
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 STAFFQUALIFICATIONS 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 SANCTIONS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 BACKGROUND CHECKS
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 virtual tour of the program.

A renewal inspection was initiated on December 28, 2022 and concluded on January 24, 2022. The director was contacted by telephone and a virtual inspection was conducted. There were 66 children present, ranging in ages from three months to five years, with 27 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 five child records and six 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.

Violations

4
Standard 22.1-289.035-B-2
Based on a review of five staff records and interview, the center did not ensure one staff
member completed a national fingerprint check prior to the first day of employment and within
the required time frame.

Evidence:

1. The national fingerprint check for Staff #2, hired 08/22/2021, was dated 04/26/2021 exceeding 90 days prior to employment. 2. Human Resource reported Staff #2 employment date was delayed based on waiting for out of state checks to be received and a new updated fingerprint was not conducted. 3. Fingerprint background check are required prior to hire and can not be any older than 90 days.
Plan of Correction: Per HR: We will ensure fingerprints are completed prior to hire and are not any older than 90 days , otherwise they will be redone.
Standard 8VAC20-770-40-D-6
Based on review of five staff records and interview, the center did not ensure a required
sworn statement and central registry finding check from an applicant, licensee,
registrant, or other person required to obtain background checks was not dated more than
90 days prior to the date of employment, volunteering, or residing in the home.

Evidence:

1. The record for staff #2, hired 08/22/2021, had documentation of a sworn statement dated
04/20/2021 and a central registry check dated 05/07/2021, both exceeding 90 days prior to hire. 2. Human resource staff #2 was delayed in starting employment while waiting to receive out of state background checks.
Plan of Correction: Per HR: We will ensure background check are complete in the required time frame and that they are no older than 90 days, otherwise they will be redone.
Standard 8VAC20-780-280-B
Based on observation and interview, the center did not ensure hazardous materials such as cleaning products were kept in a locked place using a safe locking method that prevents access by children.

Evidence:

1. Cleaning products were observed in the unlocked wall cabinet in two of the toddler classrooms. 2. Staff #1 stated the one cabinet had a broken latch and could not be locked.
Plan of Correction: Corrected during inspection: Cleaning materials were removed from the broken cabinet and placed in a locked cabinet and the second cabinet was locked. Per the director; I will have maintenance repair the latch on the cabinet.
Standard 8VAC20-780-440-G
Based on observation and interview, the center did not ensure children under 12 months of age used a crib for sleeping.

Evidence:

1. Child #5, age five months, was observed sleeping on a cot in the green room. 2. Staff stated he was tired and she placed him on a cot in the play area so she could see him while he slept.
Plan of Correction: Per the director: I will review sleeping requirements with staff. Children under 12 months will sleep in their cribs rather than cots.
View original record on Virginia Department of Social Services