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St. James's Children's Center

Inspection · 2021-10-28

Date
2021-10-28
Complaint Related
No
Licensing Inspector
Susan Ellington-Sconiers
(804) 588-2368
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

22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.

Inspector Notes

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, interviews and a virtual tour of the program.

A monitoring inspection was initiated on October 28, 2021 and concluded on October 28, 2021. The director was contacted by telephone and a virtual inspection was conducted. There were 24 children present, ranging in ages from 2 years to 4 years, with 12 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 3 child records and 3 staff records were reviewed.

Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.

New requirements became effective on October 13, 2021. The facility has not yet fully complied with the requirements. The facility is to review the new requirements and work with their assigned inspector to ensure future compliance.

Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days from today. Please specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations

4
Standard 22VAC40-185-260-A
Based on a review of records and interview on October 28, 2021, the center did not ensure to obtain an annual fire inspection report from the appropriate fire official having jurisdiction.
Evidence: 1. The record of the annual fire inspection is dated 05/14/2020. 2. Administration acknowledged they have not contacted the local fire official.
Plan of Correction: Contact Fire official to get inspection done. Contact Head of Church to get copy of 2021 inspection.
Standard 22VAC40-185-550-D
Based on a review of records and interview on October 28, 2021, the center did not ensure to implement a monthly practice evacuation drill and a minimum of two shelter-in-place practice drills per year for the most likely to occur scenarios.
Evidence: 1. There was no documentation of a fire drill being practiced in July 2021. 2. Administration confirmed the drill wasn't completed in July.
Plan of Correction: Program Manager will conduct and document all monthly fire drills and shelter in place drills.
Standard 22VAC40-185-550-E
Based on a review of records and interview on October 28, 2021, the center did not maintain a record of the dates of the practice drills for one year.
Evidence: 1. The fire drill log did not contain documentation of a fire drill practiced in May 2021 and September 2021.
2. Administration confirmed the drills were conducted but not recorded.
Plan of Correction: Program manager will conduct and document all drills
Standard 22VAC40-185-70-A
Based on a review of records and interview on October 28, 2021, the center did not ensure that two or more references were checked before employment.
Evidence: 1. The record of Staff #1 (DOH 6/28/21) contains documentation of a reference that was checked and dated 7/20/21. 2. Administration stated the reference was on vacation.
Plan of Correction: Program manager and Executive Director will ensure all references are submitted before date of hire and checked and dated before hire.
View original record on Virginia Department of Social Services