Inspection · 2023-11-29
Date
2023-11-29
Complaint Related
No
Licensing Inspector
Stephanie Reed
(540) 272-6558
(540) 272-6558
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.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted beginning at 9:30 a.m. and ending at 1:30 p.m. There were 70 children in care ranging in age from four months through four years old under the supervision of eleven staff. Childcare areas, supplies and materials were observed.
Five staff and eight children's records were reviewed.
Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the facility.
Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it within five (5) calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must 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 preventive measure(s)
If you have questions regarding this inspection, contact the licensing inspector at Stephanie.Reed@doe.virginia.gov
Violations
11Standard 22.1-289.011-F
Based on observation, the center failed to ensure the findings from the most recent inspection were posted as required.
Evidence:
1. The most recent inspection conducted on 09/13/2023 was not posted.
2. The posted inspection was dated 06/02/2023 and three inspections have been conducted since the June inspection.
Evidence:
1. The most recent inspection conducted on 09/13/2023 was not posted.
2. The posted inspection was dated 06/02/2023 and three inspections have been conducted since the June inspection.
Plan of Correction: Inspection reports have been posted appropriately as of date. DL will verify this on bi-weekly visits.
Standard 22.1-289.035-B-4
REPEAT VIOLATION
Based on review of documentation, the center failed to request out of state central registry background checks within 30 days of employment for any staff that resided outside of Virginia in the last five years. Evidence: Staff #3, hired 9/18/2023, indicated out of state residence in North Carolina and there was no documentation of the center requesting the out of state background check.
Based on review of documentation, the center failed to request out of state central registry background checks within 30 days of employment for any staff that resided outside of Virginia in the last five years. Evidence: Staff #3, hired 9/18/2023, indicated out of state residence in North Carolina and there was no documentation of the center requesting the out of state background check.
Plan of Correction: This background checks has been complete. Moving forward, CD will use a tracking system to ensure compliance of all background checks. DL will check files twice a month to ensure compliance.
Standard 8VAC20-770-60-C-2
REPEAT VIOLATION
Based on review of documentation, the center failed to ensure that central registry background check results were obtained within 30 days of employment.
Evidence: The central registry results for Staff #3, hired on 09/18/2023, were dated 11/01/2023. The central registry results for Staff #4, hired on 02/27/2023, were dated 04/19/2023.
Based on review of documentation, the center failed to ensure that central registry background check results were obtained within 30 days of employment.
Evidence: The central registry results for Staff #3, hired on 09/18/2023, were dated 11/01/2023. The central registry results for Staff #4, hired on 02/27/2023, were dated 04/19/2023.
Plan of Correction: Beginning in December 2023, an additional center director will support the center. Part of that support will be updating and maintaining staff files to ensure compliance. DL will be checking staff files during bi-weekly center visit cadence.
Standard 8VAC20-780-160-A
Based on review of documentation, the center failed to obtain documentation of TB screening before staff came into contact with children. Evidence: Staff #4 began work on 02/27/2023 and documentation of a TB test/screening was not obtained until 03/15/2023.
Plan of Correction: Beginning in December 2023, an additional center director will support the center. Part of that support will be updating and maintaining staff files to ensure compliance. DL will be checking staff files two a month.
Standard 8VAC20-780-270-A
Based on observation, the center failed to ensure that all areas were maintained in clean, safe, operable condition.
Evidence: In the two?s room, the left sink was missing a handle and did not turn on. Under the paper towel holder there was a two to three inch size patch of chipped pain, that exposed the drywall underneath.
Evidence: In the two?s room, the left sink was missing a handle and did not turn on. Under the paper towel holder there was a two to three inch size patch of chipped pain, that exposed the drywall underneath.
Plan of Correction: The sink and drywall repairs were immediately fixed. Center has implemented our monthly Center Safety Inspection Report and will help us ensure the center is safely maintained.
Standard 8VAC20-780-280-B
Based on observation, the center failed to ensure that potentially hazardous substances were kept in a locked place.
Evidence:
1. In the younger infant room, there were two cans of Lysol, one container of disinfectant wipes unlocked on a high shelf.
2. In the toddler room, there was a bottle labeled sanitizer on top of the diapering table.
3. In the two year old room, there were disinfectant wipe in the window of the classroom.
Evidence:
1. In the younger infant room, there were two cans of Lysol, one container of disinfectant wipes unlocked on a high shelf.
2. In the toddler room, there was a bottle labeled sanitizer on top of the diapering table.
3. In the two year old room, there were disinfectant wipe in the window of the classroom.
Plan of Correction: Teachers were retrained on 12/19/23 on how to properly lock cleaning chemicals in classrooms. Current CD, supporting CD, and/ DL will check daily to ensure that cleaning chemicals are properly stored.
Standard 8VAC20-780-340-A
REPEAT VIOLATION
Based on observation, the center failed to ensure that while staff are supervising children, they shall always ensure the care, protection and guidance. of the children in care.
Evidence:
1. in the younger infant room, infant #1 was observed with the mostly empty bottle of infant #2 in their mouth and tipping it to attempt to drink from the bottle. Staff interviews revealed that that Infant #2?s bottle contained breast milk.
2. In the two year old room, children were observed for approximately 10 minutes climbing tables; throwing toys, such as blocks and pretend food; climbing on top of bins; smacking and pinching each other; pulling hair; and crying. One child was observed climbing the back of a chair and intentionally falling backwards into a clothes basket at least two times over the course of several minutes before this activity was observed by staff.
While the above behavior and activity is taking place, Staff #2 was observed with their back to the group of children, taking a box outside on the playground for approximately one minute. Staff #2 returned inside, retrieved scissors and then returned to the exit door with their back to the classroom, door half closed while breaking down the box for approximately 45 seconds.
Based on observation, the center failed to ensure that while staff are supervising children, they shall always ensure the care, protection and guidance. of the children in care.
Evidence:
1. in the younger infant room, infant #1 was observed with the mostly empty bottle of infant #2 in their mouth and tipping it to attempt to drink from the bottle. Staff interviews revealed that that Infant #2?s bottle contained breast milk.
2. In the two year old room, children were observed for approximately 10 minutes climbing tables; throwing toys, such as blocks and pretend food; climbing on top of bins; smacking and pinching each other; pulling hair; and crying. One child was observed climbing the back of a chair and intentionally falling backwards into a clothes basket at least two times over the course of several minutes before this activity was observed by staff.
While the above behavior and activity is taking place, Staff #2 was observed with their back to the group of children, taking a box outside on the playground for approximately one minute. Staff #2 returned inside, retrieved scissors and then returned to the exit door with their back to the classroom, door half closed while breaking down the box for approximately 45 seconds.
Plan of Correction: Staff were retrained by district leader on all aspects of supervision on Tuesday, December 19th. Additionally, classroom management techniques were reviewed and practice during the training on 12/19. Supporting CD (center director), current CD, and DL (district leader) will all complete classroom observations weekly to ensure teachers are using best practices.
Standard 8VAC20-780-350-B-3
Based on observation, the center failed to ensure that maintain the 1:8 staff-to-children ratios were met for two year olds.
Evidence: On 11/29/2023 there were 18 two year old children under the supervision of 2 two staff members.
Evidence: On 11/29/2023 there were 18 two year old children under the supervision of 2 two staff members.
Plan of Correction: Proper tracking of staff to child ratios were part of the 12/19/2023 staff retraining. DL ensured there are practices in place to always support proper ratio. Additional CD support at the center will help to ensure proper ratio is always maintained.
Standard 8VAC20-780-500-A
Based on observation, the center failed to ensure that staff washed their hands after coming into contact with body fluids.
Evidence: In the two year old room, Staff #2 was observed wiping the noses of several children and Staff #2 did not wash their hands in between or after wiping each child?s nose.
Evidence: In the two year old room, Staff #2 was observed wiping the noses of several children and Staff #2 did not wash their hands in between or after wiping each child?s nose.
Plan of Correction: On 12/7/23, teachers were retrained on proper hand washing techniques. Current CD, supporting CD and DL will verify proper hand washing through weekly classroom observations
Standard 8VAC20-780-500-B
Based on observation, the center failed to ensure that there was a leakproof covered receptacle for soiled linens.
Evidence: The soiled linen containers observed in the infant room, older infant room, toddler room and two?s room, were open laundry baskets with cut outs that were not covered nor leakproof.
Evidence: The soiled linen containers observed in the infant room, older infant room, toddler room and two?s room, were open laundry baskets with cut outs that were not covered nor leakproof.
Plan of Correction: As of date, center has correct receptacles in use
Standard 8VAC20-780-570-E
Based on observation, the center failed to ensure all prepared infant bottles were labeled and dated as required.
Evidence: In the younger infant room, there were three infant bottles not labeled with the child?s name.
Evidence: In the younger infant room, there were three infant bottles not labeled with the child?s name.
Plan of Correction: Teachers were retrained on proper bottle labeling by December 7th . Additionally, current CD, supporting CD, and DL will complete weekly observations to ensure bottles are properly labeled.