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Virginia Commonwealth University Health System Authority -N Deck

Inspection · 2025-01-23

Date
2025-01-23
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

8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services
8VAC20-780 Administration.
20 Access to minor?s records
8VAC20-780 Staff Qualifications and Training.
22.1 Early Childhood Care and Education
8VAC20-780 Physical Plant.
63.2 Child Abuse & Neglect
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

During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.

Inspector Notes

An unannounced, on-site monitoring inspection was initiated on 01/23/2025 and completed on 02/04/2025. The on-site inspection began at 9:46am and ended at 12:45pm. The inspector reviewed compliance in the areas listed above. There were 113 children present and 25 staff. The inspector reviewed 10 children?s records and 10 staff records electronically on 01/29/2025. This inspection included document review, and tour of the facility.

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 violation will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 02/11/2025. A POC submitted after this date will not appear on the public website.

Violations

4
Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employee's first day of employment.

Staff #2, who had been employed for four days, did not have a completed national criminal background check. Staff #8 had a completed national criminal background check dated 15 days after their date of employment. Staff #10 had a completed national criminal background check dated 17 days after their date of employment.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-160-A
Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment.

Staff #7 TB was dated 48 days prior to their date of employment.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-270-A
The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition.

In classroom #6, a large area rug was laying on top of finished floor that was unraveling at the corner ends and was a tripping hazard.
In classroom #8, a metal step trashcan was rusty and in reach of children.
On the playground, a hole in the ground did not have a covering, creating a tripping hazard.
Plan of Correction: Order placed for new trashcan. Facilities ticket submitted for hole on playground. Rug will be fixed after children wake from naptime.
Standard 8VAC20-780-510-E
The centers procedures for administering medication includes methods to prevent use of outdated medication.

The medication for child #15 had expired one month ago.
Plan of Correction: Medication sent home today.
View original record on Virginia Department of Social Services