Inspection · 2022-04-12
Date
2022-04-12
Complaint Related
No
Licensing Inspector
Brandie Viscayda
(757) 636-3427
(757) 636-3427
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)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced monitoring inspection was conducted on 4/12/22 from 11:30am - 1:15pm. During the inspection there were 85 children ages three years old through twelve years old in care with 9 staff. Children were observed participating in various activities in the classrooms, eating lunch and during rest period. Records were reviewed for eight children and nine staff. Medication, emergency procedures, and emergency supplies were reviewed during the inspection. Areas of non-compliance are identified on the violation notice and were discussed during the exit interview.
Violations
11Standard 22.1-289.035-B-2
Based on a review of nine staff records, it was determined that the facility did not ensure that an employee is allowed to begin employment without a completed national criminal history record check (finger printing).
Evidence:
1. The record for staff #1, working during the inspection, did not contain a completed national criminal history record check (finger printing).
2. The record for staff #3 working during the inspection, did not contain a completed national criminal history record check (finger printing).
3. The record for staff #5, working during the inspection, did not contain a completed national criminal history record check (finger printing).
4. The record for staff #6, working during the inspection, did not contain a completed national criminal history record check (finger printing).
5. The record for staff #7, working during the inspection, did not contain a completed national criminal history record check (finger printing).
6. The record for staff #8, working during the inspection, did not contain a completed national criminal history record check (finger printing).
7. The record for staff #9, working during the inspection, did not contain a completed national criminal history record check (finger printing).
8. Staff #4 (Program Director) confirmed the completed national criminal history record check (finger printing) was not completed prior to employment for any of the staff listed above.
Evidence:
1. The record for staff #1, working during the inspection, did not contain a completed national criminal history record check (finger printing).
2. The record for staff #3 working during the inspection, did not contain a completed national criminal history record check (finger printing).
3. The record for staff #5, working during the inspection, did not contain a completed national criminal history record check (finger printing).
4. The record for staff #6, working during the inspection, did not contain a completed national criminal history record check (finger printing).
5. The record for staff #7, working during the inspection, did not contain a completed national criminal history record check (finger printing).
6. The record for staff #8, working during the inspection, did not contain a completed national criminal history record check (finger printing).
7. The record for staff #9, working during the inspection, did not contain a completed national criminal history record check (finger printing).
8. Staff #4 (Program Director) confirmed the completed national criminal history record check (finger printing) was not completed prior to employment for any of the staff listed above.
Plan of Correction: The facility responded: Having all employees schedule an appointment as they come into work, will send copies when completed. Moving forward, I will have ALL staff members schedule this BEFORE they start working at the field house.
Standard 22.1-289.035-B-4
Based on a review of nine staff records, it was determined that the facility did not ensure that they obtain a copy of the results of a sex offender registry check from any state in which the individual has resided in the preceding five years prior to employment.
Evidence:
1. The record for staff #5, working during the inspection, did not contain documentation of a completed sex offender registry check from Hawaii. The sworn statement indicated staff #5 had previously lived in Hawaii within the last 5 years.
2. Staff #4 (Program Director) confirmed the sex offender registry check from the State of Hawaii was received prior to start of employment for staff #5.
Evidence:
1. The record for staff #5, working during the inspection, did not contain documentation of a completed sex offender registry check from Hawaii. The sworn statement indicated staff #5 had previously lived in Hawaii within the last 5 years.
2. Staff #4 (Program Director) confirmed the sex offender registry check from the State of Hawaii was received prior to start of employment for staff #5.
Plan of Correction: The facility responded: Staff #5 will complete a sex offender check and a search of the centyral registry for Hawaii.
Standard 8VAC20-770-60-B
Based on a review of nine staff records, it was determined that the facility did not ensure that the facility did not ensure that an employee must not be employed until a sworn statement or affirmation has been completed.
Evidence:
1. The record for staff #1, working during the inspection, did not contain a sworn statement or affirmation.
2 .The record for staff #2, working during the inspection, did not contain a sworn statement or affirmation.
3. The record for staff #3 working during the inspection, did not contain a sworn statement or affirmation.
4. The record for staff #5, working during the inspection, did not contain a sworn statement or affirmation.
5. The record for staff #6, working during the inspection, did not contain a sworn statement or affirmation.
6. The record for staff #7, working during the inspection, did not contain a sworn statement or affirmation.
7. The record for staff #8, working during the inspection, did not contain a sworn statement or affirmation.
8. The record for staff #9, working during the inspection, did not contain a sworn statement or affirmation.
9. Staff #4 (Program Director) confirmed the sworn statement or affirmation was not completed prior to employment for any of the staff listed above.
Evidence:
1. The record for staff #1, working during the inspection, did not contain a sworn statement or affirmation.
2 .The record for staff #2, working during the inspection, did not contain a sworn statement or affirmation.
3. The record for staff #3 working during the inspection, did not contain a sworn statement or affirmation.
4. The record for staff #5, working during the inspection, did not contain a sworn statement or affirmation.
5. The record for staff #6, working during the inspection, did not contain a sworn statement or affirmation.
6. The record for staff #7, working during the inspection, did not contain a sworn statement or affirmation.
7. The record for staff #8, working during the inspection, did not contain a sworn statement or affirmation.
8. The record for staff #9, working during the inspection, did not contain a sworn statement or affirmation.
9. Staff #4 (Program Director) confirmed the sworn statement or affirmation was not completed prior to employment for any of the staff listed above.
Plan of Correction: The facility responded: Had all employees sign and sent off day after inspection, and will also require this as part of the application process moving forward .
Standard 8VAC20-780-160-A
Based on a review of nine staff records, it was determined that the facility did not ensure that each staff member shall submit documentation of a negative tuberculosis screening prior to employment beginning
Evidence:
1. The record for staff #1, present during the inspection, did not contain documentation of a negative tuberculosis screening.
2.The record for staff #2, present during the inspection, did not contain documentation of a negative tuberculosis screening.
3. The record for staff #3, present during the inspection, did not contain documentation of a negative tuberculosis screening.
4. The record for staff #5, present during the inspection, did not contain documentation of a negative tuberculosis screening.
5. The record for staff #6, present during the inspection, did not contain documentation of a negative tuberculosis screening.
6. The record for staff #7, present during the inspection, did not contain documentation of a negative tuberculosis screening.
7. The record for staff #8, present during the inspection, did not contain documentation of a negative tuberculosis screening.
8. The record for staff #9, present during the inspection, did not contain documentation of a negative tuberculosis screening.
8. Staff #4 (Program Director) confirmed that the documentation of a negative tuberculosis screening had not been received prior to employment for any of the staff working during the inspection.
Evidence:
1. The record for staff #1, present during the inspection, did not contain documentation of a negative tuberculosis screening.
2.The record for staff #2, present during the inspection, did not contain documentation of a negative tuberculosis screening.
3. The record for staff #3, present during the inspection, did not contain documentation of a negative tuberculosis screening.
4. The record for staff #5, present during the inspection, did not contain documentation of a negative tuberculosis screening.
5. The record for staff #6, present during the inspection, did not contain documentation of a negative tuberculosis screening.
6. The record for staff #7, present during the inspection, did not contain documentation of a negative tuberculosis screening.
7. The record for staff #8, present during the inspection, did not contain documentation of a negative tuberculosis screening.
8. The record for staff #9, present during the inspection, did not contain documentation of a negative tuberculosis screening.
8. Staff #4 (Program Director) confirmed that the documentation of a negative tuberculosis screening had not been received prior to employment for any of the staff working during the inspection.
Plan of Correction: The facility responded: I have ordered all employees to get a TB Screening before the start of camp and will also require this as part of the application process moving forward.
Standard 8VAC20-780-260-B
Based on a review of documentation and interview, it was determined that the facility did not ensure that the annual approval from the health department was received.
Evidence:
1. There was no documentation to demonstrate the annual approval from the health department had been received.
2. Staff #4 (Program Director) confirmed that there was no documentation available for viewing during the inspection that the annual approval from the health department had been received.
Evidence:
1. There was no documentation to demonstrate the annual approval from the health department had been received.
2. Staff #4 (Program Director) confirmed that there was no documentation available for viewing during the inspection that the annual approval from the health department had been received.
Plan of Correction: The facility responded: Will call to schedule a Health Inspection before the start of camp.
Standard 8VAC20-780-340-D
Based on observation, a review of five staff records and interviews, it was determined that the licensee did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present.
Evidence:
1. The Licensing Inspector observed a total of 8 staff working in four classrooms. A review of the eight staff records did not provide documentation to demonstrate that any of staff present was Program Leader qualified.
2. Staff #4 (Program Director) confirmed that there was no documentation available for viewing during the inspection to demonstrate any of the staff present was Program Leader qualified.
Evidence:
1. The Licensing Inspector observed a total of 8 staff working in four classrooms. A review of the eight staff records did not provide documentation to demonstrate that any of staff present was Program Leader qualified.
2. Staff #4 (Program Director) confirmed that there was no documentation available for viewing during the inspection to demonstrate any of the staff present was Program Leader qualified.
Plan of Correction: The facility responded: Will develop an in depth training program that will make sure that all staff are qualified to be in the classroom and have sufficient evidence of all required training.
Standard 8VAC20-780-350-B-5
Based on observation and interviews, it was determined that the facility did not ensure that for children, from nine years of age through twelve years, one staff member for every 20 children is maintained at all times children are in care.
Evidence:
1. During the inspection the Licensing Inspector observed staff #7 working with alone with 24 children in a classroom. The children in the classroom were 9-12 years old.
2. Staff #4 (Program director) confirmed that the facility did not maintain the required staff-to-child ratio for this grouping of children.
Evidence:
1. During the inspection the Licensing Inspector observed staff #7 working with alone with 24 children in a classroom. The children in the classroom were 9-12 years old.
2. Staff #4 (Program director) confirmed that the facility did not maintain the required staff-to-child ratio for this grouping of children.
Plan of Correction: The facility responded: Corrected during the inspection. Will make sure that counselors are more aware of their numbers and will always let a staff member know if they are going to be over to maintain the appropriate ratios. (Ratios were corrected at the time of inspection).
Standard 8VAC20-780-530-A
Based on a review of nine staff records and interviews, it was determined that the facility did not ensure that there shall be at least one staff in each classroom or area where children are present that has a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Evidence:
1. The Licensing Inspector observed a total of eight staff working in four classrooms with children ages three years old to twelve years old. None of the records for the eight staff working during the inspection contained documentation to demonstrate that the staff had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care
2. Staff #4 (Program Director) confirmed that none of the staff working during the inspection had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Evidence:
1. The Licensing Inspector observed a total of eight staff working in four classrooms with children ages three years old to twelve years old. None of the records for the eight staff working during the inspection contained documentation to demonstrate that the staff had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care
2. Staff #4 (Program Director) confirmed that none of the staff working during the inspection had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Plan of Correction: The facility responded: Will do a group staff CPR training to ensure all staff members are CPR Certified.
Standard 8VAC20-780-530-C
Based on a review of three staff records and interviews, it was determined that the facility did not ensure that there shall be at least two staff members who meet the requirements of subsection A of this section present on the premises during the center's hours of operation, on fieldtrips, and wherever children are in care.
Evidence:
1. The Licensing Inspector reviewed the records for all staff present and only staff #4 had a current CPR/First aid certification.
2. Staff #4 confirmed that were not two staff present a current CPR/First aid certification.
Evidence:
1. The Licensing Inspector reviewed the records for all staff present and only staff #4 had a current CPR/First aid certification.
2. Staff #4 confirmed that were not two staff present a current CPR/First aid certification.
Plan of Correction: The facility responded: Will do a group staff CPR training to ensure all staff members are CPR Certified.
Standard 8VAC20-780-560-G
Based on observation and interviews, it was determined that the licensee did not ensure that when food is brought from home it is labeled with the child's name and date.
Evidence:
1. The Licensing Inspector observed that all of the lunch boxes that the children had brought from home were not labeled with their name and the date.
2. Staff #4 (Program Director) confirmed that all of the lunch boxes used by the children at the facility were not labeled with their name or the date.
Evidence:
1. The Licensing Inspector observed that all of the lunch boxes that the children had brought from home were not labeled with their name and the date.
2. Staff #4 (Program Director) confirmed that all of the lunch boxes used by the children at the facility were not labeled with their name or the date.
Plan of Correction: The facility responded: Lunchboxes labeled/with dates: Will ensure that all children come in with labeled lunchboxes with names and dates each day.
Standard 8VAC20-780-70
Based on a review of nine staff records and interviews, it was determined that the facility did not ensure that a staff record is kept for each person with all of the required information.
Evidence:
1. Staff #1, working during the inspection, did not have a record available for viewing during the inspection.
2. Staff #2, working during the inspection, did not have a record available for viewing during the inspection.
3. Staff #3, working during the inspection, did not have a record available for viewing during the inspection.
4. Staff #5, working during the inspection, did not have a record available for viewing during the inspection.
5. Staff #6, working during the inspection, did not have a record available for viewing during the inspection.
6. Staff #7, working during the inspection, did not have a record available for viewing during the inspection.
7. Staff #8, working during the inspection, did not have a record available for viewing during the inspection.
8. Staff #9, working during the inspection, did not have a record available for viewing during the inspection.
9. Staff #4 (Program Director) confirmed that the staff listed above were allowed to begin employment without having a record with all of the required information..
Evidence:
1. Staff #1, working during the inspection, did not have a record available for viewing during the inspection.
2. Staff #2, working during the inspection, did not have a record available for viewing during the inspection.
3. Staff #3, working during the inspection, did not have a record available for viewing during the inspection.
4. Staff #5, working during the inspection, did not have a record available for viewing during the inspection.
5. Staff #6, working during the inspection, did not have a record available for viewing during the inspection.
6. Staff #7, working during the inspection, did not have a record available for viewing during the inspection.
7. Staff #8, working during the inspection, did not have a record available for viewing during the inspection.
8. Staff #9, working during the inspection, did not have a record available for viewing during the inspection.
9. Staff #4 (Program Director) confirmed that the staff listed above were allowed to begin employment without having a record with all of the required information..
Plan of Correction: The facility responded: I am gathering all the necessary paperwork together and creating staff files with the checklists provided from the Licensing Inspector.