Inspection · 2023-12-07
Date
2023-12-07
Complaint Related
No
Licensing Inspector
Jennifer Moore
(540) 430-0384
(540) 430-0384
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minors records
22.1 Background Checks Code, Carbon Monoxide
22.1 Early Childhood Care and Education
Inspector Notes
An unannounced renewal inspection was initiated on 12/7/2023 and concluded on 12/8/2023. The inspector was on site on 12/7/2023 from approximately 9:38 am-12:10 pm. There were 27 children present, ranging in ages from 18 months to 5 years, with 13 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies, nutrition and background checks. A total of 5 child records, 12 staff records, and 1 officer record were reviewed. Staff records were reviewed on site and remotely on 12/8/2023.
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.
Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.
Violations
8Standard 22.1-289.035-B-2
Based on a review of 12 staff records and interview, the center did not ensure that two staff completed a fingerprint background check prior to the first date of employment as required.
Evidence:
1. The record of staff #8 (date of employment: 9/5/23) contained a fingerprint background check dated 9/6/23. The record of staff #12 (date of employment: 8/25/23) did not contain a fingerprint background check.
2. Administration acknowledged that the fingerprint checks were not completed prior to employment for the two staff.
Evidence:
1. The record of staff #8 (date of employment: 9/5/23) contained a fingerprint background check dated 9/6/23. The record of staff #12 (date of employment: 8/25/23) did not contain a fingerprint background check.
2. Administration acknowledged that the fingerprint checks were not completed prior to employment for the two staff.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.036-A
Based on a review of records, the center did not ensure to obtain the required repeat background checks every five years for one officer of the public agency.
Evidence:
1. The record of officer #1 contained a fingerprint background check dated 3/29/18 and a central registry background check dated 6/8/17.
2. Administration acknowledged that the repeat background checks had not been completed.
Evidence:
1. The record of officer #1 contained a fingerprint background check dated 3/29/18 and a central registry background check dated 6/8/17.
2. Administration acknowledged that the repeat background checks had not been completed.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-60-B
Based on a review of 12 staff records and interview, the center did not ensure that one staff completed a sworn statement prior to their first date of employment as required.
Evidence:
1. The record of staff #2 (date of employment: 8/25/23) contained a sworn statement dated 9/29/23.
2. Administration acknowledged that the sworn statement was completed after the start of employment.
Evidence:
1. The record of staff #2 (date of employment: 8/25/23) contained a sworn statement dated 9/29/23.
2. Administration acknowledged that the sworn statement was completed after the start of employment.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-60-C-2
Based on a review of 12 staff records and interview, the center did not ensure to obtain a central registry finding for 10 staff within 30 days of employment as required.
Evidence:
1. The record of staff #2 (date of employment: 8/25/23) contained a central registry finding dated 10/1/23. The record of staff #3 (date of employment: 8/25/23) did not contain a central registry finding. The record of staff #4 (date of employment: 6/8/23) did not contain a central registry finding. The record of staff #5 (date of employment: 8/29/23) contained a central registry finding dated 11/16/23. The record of staff #6 (date of employment: 6/21/23) contained a central registry finding dated 10/1/23. The record of staff #7 (date of employment: 8/28/23) contained a central registry finding dated 10/1/23. The record of staff #9 (date of employment: 9/25/23) did not contain a central registry finding. The record of staff #10 (date of employment: 9/13/23) did not contain a central registry finding. The record of staff #11 (date of employment: 10/3/23) did not contain a central registry finding. The record of staff #12 (date of employment: 8/25/23) did not contain a central registry finding.
2. Administration acknowledged that the central registry findings listed were not received within the required time frame.
Evidence:
1. The record of staff #2 (date of employment: 8/25/23) contained a central registry finding dated 10/1/23. The record of staff #3 (date of employment: 8/25/23) did not contain a central registry finding. The record of staff #4 (date of employment: 6/8/23) did not contain a central registry finding. The record of staff #5 (date of employment: 8/29/23) contained a central registry finding dated 11/16/23. The record of staff #6 (date of employment: 6/21/23) contained a central registry finding dated 10/1/23. The record of staff #7 (date of employment: 8/28/23) contained a central registry finding dated 10/1/23. The record of staff #9 (date of employment: 9/25/23) did not contain a central registry finding. The record of staff #10 (date of employment: 9/13/23) did not contain a central registry finding. The record of staff #11 (date of employment: 10/3/23) did not contain a central registry finding. The record of staff #12 (date of employment: 8/25/23) did not contain a central registry finding.
2. Administration acknowledged that the central registry findings listed were not received within the required time frame.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-160-A
Based on a review of 12 staff records and interview, the center did not ensure to obtain documentation of a negative tuberculosis (TB) screening for 6 staff at the time of employment and prior to coming into contact with children.
Evidence:
1. The record of staff #5 (date of employment: 8/29/23) contained a TB screening dated 9/2/23. The record of staff #6 (date of employment: 6/21/23) contained a TB screening dated 6/24/23. The record of staff #7 (date of employment: 8/28/23) contained a TB screening dated 9/3/23. The record of staff #8 (date of employment: 9/5/23) contained a TB screening dated 9/7/23. The record of staff #9 (date of employment: 9/25/23) did not contain a TB screening. The record of staff #10 (date of employment: 9/13/23) contained a TB screening dated 9/15/23.
2. Administration acknowledged that the TB screenings were submitted after the start of employment.
Evidence:
1. The record of staff #5 (date of employment: 8/29/23) contained a TB screening dated 9/2/23. The record of staff #6 (date of employment: 6/21/23) contained a TB screening dated 6/24/23. The record of staff #7 (date of employment: 8/28/23) contained a TB screening dated 9/3/23. The record of staff #8 (date of employment: 9/5/23) contained a TB screening dated 9/7/23. The record of staff #9 (date of employment: 9/25/23) did not contain a TB screening. The record of staff #10 (date of employment: 9/13/23) contained a TB screening dated 9/15/23.
2. Administration acknowledged that the TB screenings were submitted after the start of employment.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-240-A
Based on a review of 12 staff records and interview, the center did not ensure that 1 staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment as required.
Evidence:
1. The record of staff #7 (date of employment: 8/28/23) did not contain documentation of completion of the dept. sponsored orientation.
2. Administration acknowledged that the course had not been completed by staff #7.
Evidence:
1. The record of staff #7 (date of employment: 8/28/23) did not contain documentation of completion of the dept. sponsored orientation.
2. Administration acknowledged that the course had not been completed by staff #7.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-O
Based on a review of documentation and interview, the center did not ensure to notify the parents by the end of the day of any known minor injuries.
Evidence:
1. Injury reports were reviewed on 12/7/23. One injury report indicated that on 12/5/2023, a child sustained a minor injury. The date of parent notification was listed as 12/6/23.
2. Administration acknowledged that the parent was not notified the same day as the minor injury.
Evidence:
1. Injury reports were reviewed on 12/7/23. One injury report indicated that on 12/5/2023, a child sustained a minor injury. The date of parent notification was listed as 12/6/23.
2. Administration acknowledged that the parent was not notified the same day as the minor injury.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-70
Based on a review of 12 staff records and interview, the center did not ensure that a record was kept for 11 staff that contained the required information.
Evidence:
1. The record of staff #2 (date of employment: 8/25/23) did not contain documentation of the required orientation training. The record of staff #3 (date of employment: 8/25/23) did not contain documentation of the required orientation training. The record of staff #4 (date of employment: 6/8/23) did not contain documentation of the required orientation training and documentation that two or more references as to character and reputation as well as competency were checked before employment. The record of staff #5 (date of employment: 8/29/23) did not contain documentation of the required orientation training. The record of staff #6 (date of employment: 6/21/23) did not contain documentation of the required orientation training and documentation that two or more references as to character and reputation as well as competency were checked before employment. The record of staff #7 (date of employment: 8/28/23) did not contain documentation of the required orientation training and was missing one of the two required character references. The record of staff #8 (date of employment: 9/5/23) did not contain documentation of the required orientation training. The record of staff #9 (date of employment: 9/25/23) did not contain documentation of the required orientation training. The record of staff #10 (date of employment: 9/13/23) did not contain documentation of the required orientation training and was missing one of the two required character references. The record of staff #11 (date of employment: 10/3/23) did not contain documentation of the required orientation training and was missing one of the two required character references. The record of staff #12 (date of employment: 8/25/23) did not contain documentation of the required orientation training.
2. Administration stated that the orientation training was completed but not documented.
Evidence:
1. The record of staff #2 (date of employment: 8/25/23) did not contain documentation of the required orientation training. The record of staff #3 (date of employment: 8/25/23) did not contain documentation of the required orientation training. The record of staff #4 (date of employment: 6/8/23) did not contain documentation of the required orientation training and documentation that two or more references as to character and reputation as well as competency were checked before employment. The record of staff #5 (date of employment: 8/29/23) did not contain documentation of the required orientation training. The record of staff #6 (date of employment: 6/21/23) did not contain documentation of the required orientation training and documentation that two or more references as to character and reputation as well as competency were checked before employment. The record of staff #7 (date of employment: 8/28/23) did not contain documentation of the required orientation training and was missing one of the two required character references. The record of staff #8 (date of employment: 9/5/23) did not contain documentation of the required orientation training. The record of staff #9 (date of employment: 9/25/23) did not contain documentation of the required orientation training. The record of staff #10 (date of employment: 9/13/23) did not contain documentation of the required orientation training and was missing one of the two required character references. The record of staff #11 (date of employment: 10/3/23) did not contain documentation of the required orientation training and was missing one of the two required character references. The record of staff #12 (date of employment: 8/25/23) did not contain documentation of the required orientation training.
2. Administration stated that the orientation training was completed but not documented.
Plan of Correction: Not available online. Contact Inspector for more information.