Inspection · 2025-01-08
Licensing Inspector
Cindy Horne
(804) 297-4469
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.
8VAC20-820 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 renewal inspection was initiated on 1/08/2025. The on-site inspection began at 2:10 p.m. and ended at 4:36 p.m. The inspector reviewed compliance in the areas listed above. There were 14 children present and three staff. The inspector reviewed five children?s records and five staff records on-site. This inspection included document review (i.e. Injury logs, emergency drill logs, health inspection, fire inspection, liability insurance), tour of the facility, interviews, and observations. Additional information was received after the inspection. The violation notice was revised and the inspection was completed on 1/16/2025.
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 1/23/2025. A POC submitted after this date will not appear on the public website.
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 #1, who had been employed for more than 4 weeks, did not have a completed national criminal background check.
Plan of Correction: Called and will be emailed on 1/09/2025.
Standard 22.1-289.036-A
The center is required to have applicants undergo a background check every five years. The most recent national criminal background check for applicant #1 was overdue by a year and seven months.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.057-A
The program is required to submit to VDH and implement a plan to test potable water for lead. The program did not have evidence of a testing plan submitted to VDH and the program did not have evidence of the implementation of the required testing plan.
Plan of Correction: Will email leadtestingprogram@vdh.virginia.gov to find out what they need in my plan, then I will submit my lead testing plan.
Standard 8VAC20-780-160-A
Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment. The documentation shall have been completed within the last 30 calendar days of the date of employment. The tuberculosis screening for Staff #1 was dated more than a year prior to her start date. The tuberculosis screening for Staff #4 was dated more than two months prior to her start date.
Plan of Correction: New TB test
Standard 8VAC20-780-210-A
Program leaders shall receive 24 hours of training related to the care of children within six months before beginning work or one month after beginning work. Staff #1 did not have 24 hours of training documented during the required timeframes.
Plan of Correction: Finish remaining hours.
Standard 8VAC20-780-240-B
Staff shall complete orientation training prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Staff #1, who is working with children, has not yet completed this course which is overdue by 3 weeks.
Plan of Correction: New orientation will be held on 1/10/2025.
Standard 8VAC20-780-245-A
Staff shall complete a minimum of 16 hours of training annually, appropriate to the age of children in care. The most recent training documented for Staff #2 was dated 8/24/23. The most recent training documented for Staff #3 was dated 8/14/23. The most recent training documented for Staff #5 was dated 4/05/23.
Plan of Correction: Staff #2 has completed 15 hours as of 1/09. Staff #3 will do 16 hours. Staff #5 has 7 hours.
Standard 8VAC20-780-80-A
For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs. The center documents attendance electronically but they did not maintain a written record as required.
Plan of Correction: Not available online. Contact Inspector for more information.