Inspection · 2023-09-06
Date
2023-09-06
Complaint Related
No
Licensing Inspector
Arlene Agustin
(804) 629-7519
(804) 629-7519
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
8VAC20-820 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 renewal inspection was completed September 6, 2023. Inspector arrived at 11:00am and departed at approximately 1:15pm. There were 15 children and 5 staff members present. The Inspector observed five children?s records and six staff records. The Inspector observed staff and children?s interactions throughout the inspection. Children were observed during indoor play, lunch, handwashing, and transition to nap. Emergency preparedness documents were observed. Transportation van was observed. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented. The violations are listed on the violation notice issued to the center and were reviewed with the owner and the Director at the exit interview.
Violations
11Standard 8VAC20-770-60-B
Based on record review and interview, it was determined that the center did not ensure that sworn statements were completed prior to the first day of employment.
Evidence:
1. Three of the six staff records that were reviewed did not have a signed sworn statement completed prior to the first day of employment.
a. Staff #2 (date of hire 6/01/2023) did not have a signed sworn statement.
b. Staff #3 (date of hire 1/01/2023) did not have a signed sworn statement.
c. Staff #5 (date of hire 2/18/2020) did not have a signed sworn statement.
2. Staff #1, the owner, confirmed that there were no sworn statements completed for the three staff members.
Evidence:
1. Three of the six staff records that were reviewed did not have a signed sworn statement completed prior to the first day of employment.
a. Staff #2 (date of hire 6/01/2023) did not have a signed sworn statement.
b. Staff #3 (date of hire 1/01/2023) did not have a signed sworn statement.
c. Staff #5 (date of hire 2/18/2020) did not have a signed sworn statement.
2. Staff #1, the owner, confirmed that there were no sworn statements completed for the three staff members.
Plan of Correction: All files have been updated with new forms
Standard 8VAC20-770-60-C-2
Based on record review and interview, it was determined that the center did not ensure that central registry results, by the end of the 30th day of employment, were completed.
Evidence:
1. Staff #2 did not have a completed Virginia central registry check completed by the end of the 30th day of employment.
2. Staff #1 the owner confirmed that the results of the Virginia central registry for Staff #2 was not completed by the end of the 30th day of employment.
Evidence:
1. Staff #2 did not have a completed Virginia central registry check completed by the end of the 30th day of employment.
2. Staff #1 the owner confirmed that the results of the Virginia central registry for Staff #2 was not completed by the end of the 30th day of employment.
Plan of Correction: The central registry was completed and submitted back in May and was followed up once in June & July
with no information. There will be a new registry sent & it will be followed up every week until it has
returned. Until the documentation comes back she will be removed from the schedule.
with no information. There will be a new registry sent & it will be followed up every week until it has
returned. Until the documentation comes back she will be removed from the schedule.
Standard 8VAC20-780-140-A
8VAC20-780-140. A.=B1
Based on record review and interview, it was determined that the center did not ensure that each child shall have a physical examination by or under the direction of a physician: 1. Before the child's attendance; or 2. Within 30 days after the first day of attendance.
Evidence:
1. Child #1 (date of enrollment 8/25/2022) did not have a physical examination in their record.
2. Child #2 (date of enrollment 8/07/2020) did not have a physical examination in their record.
3. Staff #1 confirmed that there was no physical examination for Child #1 and Child #2.
Based on record review and interview, it was determined that the center did not ensure that each child shall have a physical examination by or under the direction of a physician: 1. Before the child's attendance; or 2. Within 30 days after the first day of attendance.
Evidence:
1. Child #1 (date of enrollment 8/25/2022) did not have a physical examination in their record.
2. Child #2 (date of enrollment 8/07/2020) did not have a physical examination in their record.
3. Staff #1 confirmed that there was no physical examination for Child #1 and Child #2.
Plan of Correction: The center has done a review and put in place a plan to have parents update all documentation in their
files. The director will review files 2x a month to ensure the accuracy of all items in each file.
files. The director will review files 2x a month to ensure the accuracy of all items in each file.
Standard 8VAC20-780-160-A
Based on record review and interview, it was determined that the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening. 1. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. 2. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
Evidence:
1. Staff #2 (date of hire 06/01/2023) did not have a tuberculosis screening on file.
2. Staff #3 (date of hire 01/01/2023) had a tuberculosis screening dated 09/13/2021, which is outside the last 30 calendar days of the date of employment.
3. Staff #1 confirmed that Staff #2 did not have a tuberculosis screening completed prior to the date of employment. Staff #3 had a tuberculosis screenings which was outside of the 30 day calendar days of the date of employment.
Evidence:
1. Staff #2 (date of hire 06/01/2023) did not have a tuberculosis screening on file.
2. Staff #3 (date of hire 01/01/2023) had a tuberculosis screening dated 09/13/2021, which is outside the last 30 calendar days of the date of employment.
3. Staff #1 confirmed that Staff #2 did not have a tuberculosis screening completed prior to the date of employment. Staff #3 had a tuberculosis screenings which was outside of the 30 day calendar days of the date of employment.
Plan of Correction: TB?s were corrected and updated the next day after the inspection. All staff went together and had their
screenings complete.
screenings complete.
Standard 8VAC20-780-160-C
Based on record review and interview, it was determined that the center did not ensure that at least every two years from the date of the initial screening or testing, or more frequently if recommended by a licensed physician or the local health department, staff members shall obtain and submit the results of a follow-up tuberculosis screening.
Evidence:
1. Four of the six staff records reviewed had expired tuberculosis screening.
a. Staff #1 has a tuberculosis screening that expired on 05/05/2021.
b. Staff #4 has a tuberculosis screening that expired on 06/14/2019.
c. Staff #5 has a tuberculosis screening that expired on 01/30/2020.
d. Staff #6 has a tuberculosis screening that expired on 07/08/2021.
2. Staff #1 confirmed that four of the staff members have expired tuberculosis screenings.
Evidence:
1. Four of the six staff records reviewed had expired tuberculosis screening.
a. Staff #1 has a tuberculosis screening that expired on 05/05/2021.
b. Staff #4 has a tuberculosis screening that expired on 06/14/2019.
c. Staff #5 has a tuberculosis screening that expired on 01/30/2020.
d. Staff #6 has a tuberculosis screening that expired on 07/08/2021.
2. Staff #1 confirmed that four of the staff members have expired tuberculosis screenings.
Plan of Correction: All TB?s were corrected and updated the next day after the inspection. All staff went together and had
their screenings complete.
their screenings complete.
Standard 8VAC20-780-240-I
Based on record review and interview, it was determined that the center did not ensure that documentation of orientation training shall be kept by the center in a manner that allows for identification by individual staff member, is considered part of the staff member's record, and shall include: 1. Name of staff; 2. Training topics; 3. Training delivery method; 4. The entity or individual providing training; and 5. The date of training.
Evidence:
1. Three of the six records reviewed did not have documentation of orientation training.
a. Staff #2 (date of hire 6/01/2023) did not have documentation of training.
b. Staff #3 (date of hire 01/01/2023) did not have documentation of training.
c. Staff #4 (date of hire 6/14/2019) did not have documentation of training.
Evidence:
1. Three of the six records reviewed did not have documentation of orientation training.
a. Staff #2 (date of hire 6/01/2023) did not have documentation of training.
b. Staff #3 (date of hire 01/01/2023) did not have documentation of training.
c. Staff #4 (date of hire 6/14/2019) did not have documentation of training.
Plan of Correction: All files have all documentation added as of last inspection
Standard 8VAC20-780-260-A
Based on record review and interview, it was determined that the center was unable to provide to the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction.
Evidence:
1. The most recent fire inspection report from the City of Norfolk was dated May 4, 2022.
2. Staff #1 was unable to provide to the licensing representative an annual fire inspection report and the most recent one was dated May 4, 2022.
Evidence:
1. The most recent fire inspection report from the City of Norfolk was dated May 4, 2022.
2. Staff #1 was unable to provide to the licensing representative an annual fire inspection report and the most recent one was dated May 4, 2022.
Plan of Correction: Fire inspection was emailed over to inspector
Standard 8VAC20-780-270-A
Based on observation and interview, it was determined that the center did not ensure that areas and equipment of the center be maintained in a safe and operable condition.
Evidence:
1. There is peeling paint to the walls near the front entrance and two front classrooms.
2. In the 3 year old classroom, there is a bulletin board with two exposed screws that are in reach of the children. This poses as an injury hazard to the children in care.
3. On the playground, the following toys were cracked which pose as pinching and injury hazards to the children in care:
a. A pink toy jeep has a broken door;
b. The red car, which is a size of a push wagon, has a cracked hood approximately 2 feet long;
c. The white scooter that children can ride and sit on is cracked all throughout the seat and size of the scooter.
4. The plastic toy kitchen in the infant room has broken handles to the play kitchen doors. This poses as an injury hazard to the children in care.
5. Staff #5 confirmed that the toys in the playground are cracked and pose as injury hazards to the children in care.
6. Staff #5 confirmed that the kitchen in the infant room has broken handles.
Evidence:
1. There is peeling paint to the walls near the front entrance and two front classrooms.
2. In the 3 year old classroom, there is a bulletin board with two exposed screws that are in reach of the children. This poses as an injury hazard to the children in care.
3. On the playground, the following toys were cracked which pose as pinching and injury hazards to the children in care:
a. A pink toy jeep has a broken door;
b. The red car, which is a size of a push wagon, has a cracked hood approximately 2 feet long;
c. The white scooter that children can ride and sit on is cracked all throughout the seat and size of the scooter.
4. The plastic toy kitchen in the infant room has broken handles to the play kitchen doors. This poses as an injury hazard to the children in care.
5. Staff #5 confirmed that the toys in the playground are cracked and pose as injury hazards to the children in care.
6. Staff #5 confirmed that the kitchen in the infant room has broken handles.
Plan of Correction: Every Friday the teachers will go over a checklist for the end of the week to ensure all toys are safe for
the children.
the children.
Standard 8VAC20-780-500-B
Based on observation and interview, it was determined that the center did not ensure that the diapering area shall have a nonabsorbent surface for diapering or changing.
Evidence:
1. The changing pad located in the infant room has tears to the padding making it an absorbent surface for diapering or changing.
2. Staff #1 and Staff #5 confirmed the tears to the changing pad to the infant room and staff were using the pad throughout the day for diapering children.
Evidence:
1. The changing pad located in the infant room has tears to the padding making it an absorbent surface for diapering or changing.
2. Staff #1 and Staff #5 confirmed the tears to the changing pad to the infant room and staff were using the pad throughout the day for diapering children.
Plan of Correction: Safety belts will be ordered for the chairs, until they come in the chairs have been put up.
Standard 8VAC20-780-570-A
Based on observation and interview, it was determined that the center did not ensure that when a child is placed in a high chair, the protective belt shall be fastened securely.
Evidence:
1. During lunch, two of the three children in high chairs did not have their protective belt fastened securely.
2. Staff #5 confirmed that the straps were not securely fasten when in the high chair.
Evidence:
1. During lunch, two of the three children in high chairs did not have their protective belt fastened securely.
2. Staff #5 confirmed that the straps were not securely fasten when in the high chair.
Plan of Correction: Safety belts will be ordered for the chairs, until they come in the chairs have been put up.
Standard 8VAC20-780-70
Based on record review and interview, it was determined that the center did not ensure that the following staff records contain documentation that two or more references as to character and reputation as well as competency were checked before employment.
Evidence:
1. Three of the six records that were reviewed did not have two or more references as to character and reputation as well as competency were checked before employment.
a. Staff #2 (date of hire 6/01/2023) did not have reference checks completed.
b. Staff #3 (date of hire 1/01/2023) did not have reference checks completed.
c. Staff #4 (date of 6/14/2016) did not have reference checks completed.
2. Staff #1, the owner, confirmed that there were no reference checks documented for the three staff members.
Evidence:
1. Three of the six records that were reviewed did not have two or more references as to character and reputation as well as competency were checked before employment.
a. Staff #2 (date of hire 6/01/2023) did not have reference checks completed.
b. Staff #3 (date of hire 1/01/2023) did not have reference checks completed.
c. Staff #4 (date of 6/14/2016) did not have reference checks completed.
2. Staff #1, the owner, confirmed that there were no reference checks documented for the three staff members.
Plan of Correction: References were called but not documented, files are updated and has everything in the records based
on reference checks.
on reference checks.