Inspection · 2023-03-28
Date
2023-03-28
Complaint Related
No
Licensing Inspector
Rebecca Forestier
(540) 309-2835
(540) 309-2835
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.
8VAC20-770 BACKGROUND CHECKS
20 ACCESS TO MINOR?S RECORDS
22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE
63.2 CHILD ABUSE AND NEGLECT
Inspector Notes
An unannounced monitoring inspection was conducted on 03/28/2023. There were 28 children, 3 months- 4 years, and 5 staff members present during the inspection. The inspector reviewed compliance in the areas of administration, staff qualifications and trainings, staffing and supervision, physical plant, programs, emergencies and nutrition. The children were observed during free choice activities, participating in a craft project, going outside for large motor play, and during lunch. Infants were observed sleeping on demand. A total of 5 children?s records and 5 staff records were reviewed. The inspector discussed the following with the staff: nutrition, diapering and supervision. The inspector arrived for the inspection at 9:05 am and departed at 2:00 pm.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider.
Violations
15Standard 22.1-289.035-B-4
REPEAT VIOLATION
Based on record review, the center failed to obtain a copy of a criminal history record check and a copy of a child abuse and neglect search from any state in which the individual has resided in the preceding five years.
Evidence: The record for Staff 1 contained documentation that Staff 1 has resided outside of the state of Virginia within the preceding five years. The documented hire date for Staff 1 was 07/20/2022. There was not a criminal history record check or a copy of a child abuse and neglect search from all of the states in which the individual had resided in the preceding five years available for review during the inspection. Staff 1 was observed working during the inspection.
Based on record review, the center failed to obtain a copy of a criminal history record check and a copy of a child abuse and neglect search from any state in which the individual has resided in the preceding five years.
Evidence: The record for Staff 1 contained documentation that Staff 1 has resided outside of the state of Virginia within the preceding five years. The documented hire date for Staff 1 was 07/20/2022. There was not a criminal history record check or a copy of a child abuse and neglect search from all of the states in which the individual had resided in the preceding five years available for review during the inspection. Staff 1 was observed working during the inspection.
Plan of Correction: Will use the resource to obtain the out of state checks.
Standard 8VAC20-780-130-A
Based on record review, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence:
1. The record for Child 2 contained a documented start date of 08/24/2022. The date on the immunization record was 10/24/2022.
2. The record for Child 5 contained a documented start date of 01/23/2023. There was not an immunization record available for review during the inspection.
Evidence:
1. The record for Child 2 contained a documented start date of 08/24/2022. The date on the immunization record was 10/24/2022.
2. The record for Child 5 contained a documented start date of 01/23/2023. There was not an immunization record available for review during the inspection.
Plan of Correction: Will make sure to get the records before they start.
Standard 8VAC20-780-130-E
Based on record review, the center failed to obtain documentation of additional immunizations once every six months for children under the age of two years.
Evidence: The record for Child 4 contained a documented start date of 11/16/2021. Child 4 was determined to be 18 months old. The record for Child 4 contained two immunization records dated 11/14/2021 and 01/16/2023; additional immunizations were not obtained every 6 months between 11/14/2021 and 01/16/2023.
Evidence: The record for Child 4 contained a documented start date of 11/16/2021. Child 4 was determined to be 18 months old. The record for Child 4 contained two immunization records dated 11/14/2021 and 01/16/2023; additional immunizations were not obtained every 6 months between 11/14/2021 and 01/16/2023.
Plan of Correction: Will review the records more often.
Standard 8VAC20-780-160-A
Based on record review, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence: The record for Staff 5 contained a documented hire date of 03/17/2023; there was not documentation of a negative tuberculosis screening available for review during the inspection. Staff 5 was working at the center on 03/28/2023.
Evidence: The record for Staff 5 contained a documented hire date of 03/17/2023; there was not documentation of a negative tuberculosis screening available for review during the inspection. Staff 5 was working at the center on 03/28/2023.
Plan of Correction: Will get one done.
Standard 8VAC20-780-240-B
Based on record review, the center failed to ensure that 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.
Evidence: The record for Staff 5 contained a documented hire date of 03/17/2023. There was no documentation to verify that Staff 5 has completed orientation training. Staff 5 was working during the 03/28/2023 inspection.
Evidence: The record for Staff 5 contained a documented hire date of 03/17/2023. There was no documentation to verify that Staff 5 has completed orientation training. Staff 5 was working during the 03/28/2023 inspection.
Plan of Correction: Will complete the training with the staff.
Standard 8VAC20-780-280-B
Based on observation, the center failed to ensure that hazardous substances such as cleaning materials, insecticides and pesticides shall be kept in a locked place using a safe locking method that prevents access by children.
Evidence: The cleaning supplies cabinet located on the wall near the door of the 2 year old classroom was unlocked. The cabinet contained a container of disinfecting wipes and an aerosol spray bottle of Microban.
Evidence: The cleaning supplies cabinet located on the wall near the door of the 2 year old classroom was unlocked. The cabinet contained a container of disinfecting wipes and an aerosol spray bottle of Microban.
Plan of Correction: Will retrain the staff and do regular building walkthrough
Standard 8VAC20-780-290-A-3
Based on observations, the center failed to ensure that in areas used by children of preschool age or younger, electrical outlets shall have protective covers.
Evidence:
1. There was an uncovered outlet near the microwave of the 2 year old classroom.
2. There were 2 uncovered outlets on a surge protector located in the front door area of the building.
Evidence:
1. There was an uncovered outlet near the microwave of the 2 year old classroom.
2. There were 2 uncovered outlets on a surge protector located in the front door area of the building.
Plan of Correction: Will covet the outlets, retrain the staff and do regular building walkthrough
Standard 8VAC20-780-350-B-1
Based on observation and record review, the center failed to ensure that the required staff to child ratio, 1 staff for every 4 children for children birth-16 months, is met whenever children are in care.
Evidence:
1. At approximately 9:05 am, Staff 2 was observed arriving to the center and Staff 1 was observed caring for the Pre-K class. At approximately 9:15 am Staff 2 assumed the responsibility of the Pre-K class and Staff 1 went to the infant room.
2. Staff 3 stated that until Staff 1 arrived the infant room, at approximately 9:15 am, they had been the only staff member caring for the 8 children in the room. The youngest child in the room was determined to be 3 months old.
3. Staff 1 stated that they had not been in the infant room until Staff 2 arrived to the center.
Evidence:
1. At approximately 9:05 am, Staff 2 was observed arriving to the center and Staff 1 was observed caring for the Pre-K class. At approximately 9:15 am Staff 2 assumed the responsibility of the Pre-K class and Staff 1 went to the infant room.
2. Staff 3 stated that until Staff 1 arrived the infant room, at approximately 9:15 am, they had been the only staff member caring for the 8 children in the room. The youngest child in the room was determined to be 3 months old.
3. Staff 1 stated that they had not been in the infant room until Staff 2 arrived to the center.
Plan of Correction: Will have a staff designated to do all drop-offs and pick-ups.
Standard 8VAC20-780-350-B-3
Based on observation and record review, the center failed to ensure that the required staff to child ratio, 1 staff for every 8 children for children 2 years old, is met whenever children are in care.
Evidence: There were 11 children and 1 staff observed in the 2 year old class during the inspection. The youngest child in the room was determined to be 2 years old.
Evidence: There were 11 children and 1 staff observed in the 2 year old class during the inspection. The youngest child in the room was determined to be 2 years old.
Plan of Correction: Will either add staff or dismiss excess children.
Standard 8VAC20-780-530-A
Based on observation and record review, the center failed to ensure that at least one staff in each classroom or are where children are present shall have a current certification in CPR and first aid.
Evidence: Staff 4 was the only staff member observed in the 2 year old class. Staff 4 does not have a current certification in CPR or first aid.
Evidence: Staff 4 was the only staff member observed in the 2 year old class. Staff 4 does not have a current certification in CPR or first aid.
Plan of Correction: Will switch staff around until CPR/first-aid class is taken.
Standard 8VAC20-780-560-G
Based on observation, the center failed to ensure that milk, formula or breast milk shall not be heated or warmed directly in a microwave.
Evidence: Staff 3 was observed heating a bottle in the microwave.
Evidence: Staff 3 was observed heating a bottle in the microwave.
Plan of Correction: Will retrain the staff.
Standard 8VAC20-780-560-M
Based on observations, the center failed to ensure that no child shall be allowed to drink or eat while walking around.
Evidence: Child 4 was observed walking in the infant room while drinking a bottle.
Evidence: Child 4 was observed walking in the infant room while drinking a bottle.
Plan of Correction: Will retrain the staff.
Standard 8VAC20-780-60-A
REPEAT VIOLATION
Based on record review, the center failed to ensure that the separate record for each enrolled child shall contain all of the elements as required by the standards.
Evidence:
1. The record for Child 1 did not contain the following information: name and phone number of child?s physician; name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there was only one contact provided and the designated contact provided did not contain an address); documentation of viewing proof of the child?s identity and age; and first date of attendance.
2. The record for Child 2 did not contain the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the address for the second designated contact was incomplete).
3. The record for Child 4 did contain the following information: allergies and intolerances to medication or any other substances, and actions to take in an emergency; and documentation of child updates and confirmation of up-to-date information in the child?s record.
4. The record for Child 5 did not contain the following information: child?s sex; and the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for the designated contacts were incomplete).
Based on record review, the center failed to ensure that the separate record for each enrolled child shall contain all of the elements as required by the standards.
Evidence:
1. The record for Child 1 did not contain the following information: name and phone number of child?s physician; name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there was only one contact provided and the designated contact provided did not contain an address); documentation of viewing proof of the child?s identity and age; and first date of attendance.
2. The record for Child 2 did not contain the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the address for the second designated contact was incomplete).
3. The record for Child 4 did contain the following information: allergies and intolerances to medication or any other substances, and actions to take in an emergency; and documentation of child updates and confirmation of up-to-date information in the child?s record.
4. The record for Child 5 did not contain the following information: child?s sex; and the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for the designated contacts were incomplete).
Plan of Correction: Will review every record and begin to use the model form.
Standard 8VAC20-780-70
REPEAT VIOLATION
Based on record review and discussion with staff, the center failed to ensure that staff records contain all of the elements as required by the standards.
Evidence:
1. The record for Staff 1 did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment (there was only one reference available for review).
2. The record for Staff 4 did not contain documentation to demonstrate that the individual possesses the education, certification and experience required by the job position.
3. The record for Staff 5 did not contain the following information:documentation that two or more references as to character and reputation as well as competency were checked before employment (there were no references available for review); and documentation to demonstrate that the individual possesses the education, certification and experience required by the job position.
Based on record review and discussion with staff, the center failed to ensure that staff records contain all of the elements as required by the standards.
Evidence:
1. The record for Staff 1 did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment (there was only one reference available for review).
2. The record for Staff 4 did not contain documentation to demonstrate that the individual possesses the education, certification and experience required by the job position.
3. The record for Staff 5 did not contain the following information:documentation that two or more references as to character and reputation as well as competency were checked before employment (there were no references available for review); and documentation to demonstrate that the individual possesses the education, certification and experience required by the job position.
Plan of Correction: Will review all of the records and make the changes as needed.
Standard 8VAC20-780-80-A
REPEAT VIOLATION
Based on document review and discussion with staff, the center failed to ensure that 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.
Evidence:
1. Staff 2 stated that they take attendance at 9:00 am daily. The arrival of children is not documented as it occurs.
2. Review of the written attendance document confirmed that the daily attendance record does not document the departure of each child. Staff 3 confirmed that they do not document the departure of the children.
Based on document review and discussion with staff, the center failed to ensure that 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.
Evidence:
1. Staff 2 stated that they take attendance at 9:00 am daily. The arrival of children is not documented as it occurs.
2. Review of the written attendance document confirmed that the daily attendance record does not document the departure of each child. Staff 3 confirmed that they do not document the departure of the children.
Plan of Correction: Will use the model form.