Inspection · 2024-07-30
Date
2024-07-30
Complaint Related
No
Licensing Inspector
Leslie Perez
(703) 537-6013
(703) 537-6013
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced, on-site monitoring inspection was conducted on 7/30/2024, as a part of licensure period. The on-site inspection began at 9:08am and ended at 10:30am. The inspector reviewed compliance in the areas listed above. There were 18 children present and 5 staff. The inspector reviewed 2 children?s records and 2 staff records on-site on 7/30/2024. This inspection included document review, emergency drill logs, postings emergency supplies and authorization forms, tour of the facility, interviews and observations.
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.
A plan of Correction was created on 7/30/2024 at 12:45 with Licensing Inspector and Director.
Violations
13Standard 22.1-289.011-F
REPEAT VIOLATION
Based on observation and interview, the center did not have documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.
Evidence:
1. 5/16/24 signed inspection was not posted.
2. Acknowledgement form posted was not legible and behind another document.
Based on observation and interview, the center did not have documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.
Evidence:
1. 5/16/24 signed inspection was not posted.
2. Acknowledgement form posted was not legible and behind another document.
Plan of Correction: Center staff posted Acknowledgement form for 7/30/24 inspection and will posted completed/sign inspections upon receipt.
Standard 22.1-289.035-B-3
Based on record review and interview, the center did not have an original central registry report within 30 days of employment of a staff member.
Evidence:
1. Staff #1 file states date of hire 3/7/2024 and does not have a central registry report on record.
2. Staff stated it had been submitted and returned for missing items and was resubmitted, recently.
Evidence:
1. Staff #1 file states date of hire 3/7/2024 and does not have a central registry report on record.
2. Staff stated it had been submitted and returned for missing items and was resubmitted, recently.
Plan of Correction: Director to contact VA CRS and follow their instructions to obtain CPS search.
Standard 8VAC20-780-160-A
Based on record review, the center did not have documentation of a tuberculosis (TB) test or screening for staff completed within the last 30 calendar days of the date of employment or prior to coming into contact with children.
Evidence: Staff #1 date of TB 11/16/2023,start date 3/7/2024 .
Evidence: Staff #1 date of TB 11/16/2023,start date 3/7/2024 .
Plan of Correction: Director will ensure TB screening is completed in the designated time frame for future hires.
Standard 8VAC20-780-160-C
Based on documentation review, the center did not obtain updated tuberculosis (TB) tests or screenings for each staff member every two years.
Evidence: Staff #2 date of most recent TB report 7/25/2022.
Evidence: Staff #2 date of most recent TB report 7/25/2022.
Plan of Correction: Director to have staff schedule TB screening/test.
Standard 8VAC20-780-210-A
Based on record review, the center did not have documentation that Program leaders met required qualifications for that role.
Evidence:
1. Staff #1's file states job title is listed as Aid and Staff #1 was alone was in infant room during the entire inspection time, approximately 1 1/2 hours. There was no documentation in Staff #1's file that meets qualifications as program leader.
Evidence:
1. Staff #1's file states job title is listed as Aid and Staff #1 was alone was in infant room during the entire inspection time, approximately 1 1/2 hours. There was no documentation in Staff #1's file that meets qualifications as program leader.
Plan of Correction: Staff #1 will not be in role of Program Lead until Center Director obtains required qualifications. Director commented that due to moving locations, staff files were not complete, but that the information was obtained.
Standard 8VAC20-780-245-A
Based on document and record review, staff did not complete annually a minimum of 16 hours of training appropriate to the age of children in care.
Evidence: Staff #2 had 5 hours of training documented in record 7/2023-7/2024.
Evidence: Staff #2 had 5 hours of training documented in record 7/2023-7/2024.
Plan of Correction: Director to obtain training documentation for staff 7/2023-2024. Director will create a log to track/record training hours for staff.
Standard 8VAC20-780-430-B
Based on observation and interview, materials and equipment available were not age and stage appropriate for the children.
Evidence: 3 balloons were in a play area in use by infants. One infant attempted to put it in their mouth.
Evidence: 3 balloons were in a play area in use by infants. One infant attempted to put it in their mouth.
Plan of Correction: Item was immediately removed from children's area. Director will ensure that balloons will not be allowed at the center.
Standard 8VAC20-780-500-B
Based on observation and interview, the diapering surface was not being cleaned with soap and at least room temperature water and sanitized after each use.
Evidence: Staff reported that disinfecting wipes are used to clean diapering surface.
Evidence: Staff reported that disinfecting wipes are used to clean diapering surface.
Plan of Correction: Director to discuss with staff the use of soap and water and sanitizing spray on diaper changing surface, after diaper changes.
Standard 8VAC20-780-510-G
Based on observation and interview, medication was not labeled with the child's name, the name of the medication, the dosage amount, and the time or times to be given.
Evidence: Medication (liquid Tylenol) was found without required information (name, dosage and times)
Evidence: Medication (liquid Tylenol) was found without required information (name, dosage and times)
Plan of Correction: Medication was removed by staff/parent and stored in the adult's personal belongings.
Standard 8VAC20-780-510-L
Based on observation and interview, medication was not kept in a locked place using a safe locking method that prevents access by children.
Evidence: Medication (liquid Tylenol) was found in diapering storage which was not locked.
Evidence: Medication (liquid Tylenol) was found in diapering storage which was not locked.
Plan of Correction: Medication was removed from children's area and returned to parent/staff.
Standard 8VAC20-780-530-A-1
Based on record review and interview, the center did not have current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children in care at least one staff in each classroom or area where children are present.
Evidence: Staff #2's CPR certification expired 7/13/2024, staff was alone with 6 children taking a walk outside of the center.
Evidence: Staff #2's CPR certification expired 7/13/2024, staff was alone with 6 children taking a walk outside of the center.
Plan of Correction: Staff who do not have current CPR certification will not be alone with children. Director to schedule CPR training for all staff by 8/15/24.
Standard 8VAC20-780-530-A-2
Based on record review and interview, the center did not ensure that at least one staff in each classroom or area where children are present had current first aid certification.
Evidence: Staff #2's first aid certification expired 7/13/2024. Staff #2 was outside of the center on a walk alone with 6 children.
Evidence: Staff #2's first aid certification expired 7/13/2024. Staff #2 was outside of the center on a walk alone with 6 children.
Plan of Correction: Staff without current first aid certification will not be alone with children. Director to schedule first aid training by 8/15/24.
Standard 8VAC20-780-60-A
Based on record review, the center did not maintain and keep at the center a separate record for each child enrolled which contained all required information.
Evidence: Child #1's record did not have address of two designated people to call in an
emergency if a parent cannot be reached.
Evidence: Child #1's record did not have address of two designated people to call in an
emergency if a parent cannot be reached.
Plan of Correction: Director will request information from parents by 8/2/24