Inspection · 2021-10-05
Date
2021-10-05
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
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-80 THE LICENSING PROCESS.
22VAC40-191 Background Checks (22VAC40-191)
63.2(17) License & Registration Procedures
Inspector Notes
An unannounced renewal inspection was conducted on 10/05/2021. The inspector observed the following: physical plant, diapering, learning time, small motor play, and lunch. The inspector reviewed 5 children?s records, 5 staff records and 1 manager record. The inspector discussed the following with the Program Director: program administration, background check requirements, children and staff records, staff training, policy and procedures, nutrition, and provisions for emergencies. Information gathered during the inspection determined non-compliance with applicable standards or law and violations are documented on the violation notice issued to the provider. The inspector arrived for the inspection at 10:15 a.m. and departed at 1:10 p.m. If you have any questions, please contact Becky Forestier at 540-309-2835.
Violations
10Standard 22VAC40-185-240-A
Based on discussion with staff, the center failed to ensure that staff receive all of the trainings required by the standards by the end of their first day of assuming job responsibilities.
Evidence:
1. Staff 6 verified that Staff 1-5 have not received the following required trainings: job responsibilities and to whom they report; the policies and procedures listed in subsection B of this section and 22VAC40-185-420 A that relate to the staff member's responsibilities; the center's playground safety procedures unless the staff member will have no responsibility for playground activities or equipment; recognizing child abuse and neglect and the legal requirements for reporting suspected child abuse as required by the Code of Virginia; Confidential treatment of personal information about children in care and their families; and the standards in this chapter which relate to the staff member's responsibilities.
2. Staff 1-5 were observed working in a classroom during the 10/05/2021 inspection.
Evidence:
1. Staff 6 verified that Staff 1-5 have not received the following required trainings: job responsibilities and to whom they report; the policies and procedures listed in subsection B of this section and 22VAC40-185-420 A that relate to the staff member's responsibilities; the center's playground safety procedures unless the staff member will have no responsibility for playground activities or equipment; recognizing child abuse and neglect and the legal requirements for reporting suspected child abuse as required by the Code of Virginia; Confidential treatment of personal information about children in care and their families; and the standards in this chapter which relate to the staff member's responsibilities.
2. Staff 1-5 were observed working in a classroom during the 10/05/2021 inspection.
Plan of Correction: All staff will be fully trained prior to their start date. All current have been trained.
Standard 22VAC40-185-240-B
Based on discussion, the center failed to ensure that staff shall be provided in writing with policy and procedures as required by the standards by the end of the first day of supervising children.
Evidence:
1. Staff 6 verified that Staff 1-5 were not provided in writing with the following policy and procedures: the information required by 22VAC40-185-420-A; procedures for supervising a child who may arrive after scheduled classes or activities including field trips have begun; procedures to confirm absence of a child when the child is scheduled to arrive from another program or from an agency responsible for transporting the child to the center; procedures for identifying where attending children are at all times, including procedures to ensure that all children are accounted for before leaving a field trip site and upon return to the center; policy for any administration of medication; and procedures for response to natural and man-made disasters.
2. Staff 1-5 were observed working in a classroom during the 10/05/2021 inspection.
Evidence:
1. Staff 6 verified that Staff 1-5 were not provided in writing with the following policy and procedures: the information required by 22VAC40-185-420-A; procedures for supervising a child who may arrive after scheduled classes or activities including field trips have begun; procedures to confirm absence of a child when the child is scheduled to arrive from another program or from an agency responsible for transporting the child to the center; procedures for identifying where attending children are at all times, including procedures to ensure that all children are accounted for before leaving a field trip site and upon return to the center; policy for any administration of medication; and procedures for response to natural and man-made disasters.
2. Staff 1-5 were observed working in a classroom during the 10/05/2021 inspection.
Plan of Correction: All staff have received the Staff Handbook with policies and procedures to read.
Standard 22VAC40-185-240-D-5
Based on discussion, the center failed to ensure that there shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children.
Evidence: Staff 6 verified that no one on staff has obtained daily health observation training.
Evidence: Staff 6 verified that no one on staff has obtained daily health observation training.
Plan of Correction: Staff will participate in training on 10/30/2021.
Standard 22VAC40-185-280-B
Based on observations and discussion with staff, the center failed to ensure that hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children.
Evidence:
1. There was a clear plastic spray bottle sitting in the windowsill of the Infant Room; the staff identified the the contents of the bottle as bleach and water.
2. There was an aerosol can of Lysol on a shelf of the large wooden shelving unit in the large multi-purpose room.
3. There was a plastic container of "Buckeye Universal Cold Water Floor Stripper" on the table in the large multi-purpose room.
4. There was a container of Microban and OxiClean in an unlocked cabinet of the Pre-K Classroom.
Evidence:
1. There was a clear plastic spray bottle sitting in the windowsill of the Infant Room; the staff identified the the contents of the bottle as bleach and water.
2. There was an aerosol can of Lysol on a shelf of the large wooden shelving unit in the large multi-purpose room.
3. There was a plastic container of "Buckeye Universal Cold Water Floor Stripper" on the table in the large multi-purpose room.
4. There was a container of Microban and OxiClean in an unlocked cabinet of the Pre-K Classroom.
Plan of Correction: All cabinets have had locks added to them. Hazardous substances have been placed in locked cabinets.
Standard 22VAC40-185-280-G
Based on observations and discussion with staff, the center failed to ensure that if hazardous substances are not kept in original containers, the substitute containers shall clearly indicate their contents.
Evidence:
1. There was an unlabeled plastic spray bottle in windowsill of the Infant Room. Staff stated that the plastic spray bottle contained bleach and water.
2. There was an unlabeled plastic spray bottle in a cabinet in the Toddler Room. Staff stated that the plastic spray bottle contained bleach and water.
Evidence:
1. There was an unlabeled plastic spray bottle in windowsill of the Infant Room. Staff stated that the plastic spray bottle contained bleach and water.
2. There was an unlabeled plastic spray bottle in a cabinet in the Toddler Room. Staff stated that the plastic spray bottle contained bleach and water.
Plan of Correction: All containers have been labeled with the exacts contents and original containers are kept in locked closets.
Standard 22VAC40-185-60-A
Based on record review and discussion with staff, the center failed to ensure that the separate record for each child enrolled contained all of the elements as required by the standards.
Evidence:
1. The record for Child 1 did not contain the following information: the work phone number of each parent (an employer was listed but a work phone number was not provided), name address and phone number of two designated people to call in an emergency if a parent cannot be reached (only one designated person was provided), and the first date of attendance.
2. The record for Child 2 did not contain the following information: allergies and intolerance to food, medication, or any substances, and actions to take in an emergency situation, name of previous child day care and schools attended by the child, name of any additional programs or schools that the child is concurrently attending, and the first date of attendance.
3. The record for Child 3 did not contain the following information: health information as required by 22VAC40-185-130-22VAC40-185-150, documentation of viewing proof of the child's identity and age, and first date of attendance.
4. The record for Child 4 did not contain the following information: the work phone number of each parent (an employer was listed but a work phone number was not provided), allergies and intolerance to food, medication, or any substances, and actions to take in an emergency situation, health information as required by 22VAC40-185-130-22VAC40-185-150, name of any additional programs or schools that the child is concurrently attending, and the first date of attendance.
5. The record for Child 5 did not contain the following information: the work phone number of each parent (an employer was listed but a work phone number was not provided), 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 (the address for the second designated person was incomplete), names of persons authorized to pick up the child, health information as required by 22VAC40-185-130-22VAC40-185-150, name of any additional programs or schools that the child is concurrently attending, and the first date of attendance.
Evidence:
1. The record for Child 1 did not contain the following information: the work phone number of each parent (an employer was listed but a work phone number was not provided), name address and phone number of two designated people to call in an emergency if a parent cannot be reached (only one designated person was provided), and the first date of attendance.
2. The record for Child 2 did not contain the following information: allergies and intolerance to food, medication, or any substances, and actions to take in an emergency situation, name of previous child day care and schools attended by the child, name of any additional programs or schools that the child is concurrently attending, and the first date of attendance.
3. The record for Child 3 did not contain the following information: health information as required by 22VAC40-185-130-22VAC40-185-150, documentation of viewing proof of the child's identity and age, and first date of attendance.
4. The record for Child 4 did not contain the following information: the work phone number of each parent (an employer was listed but a work phone number was not provided), allergies and intolerance to food, medication, or any substances, and actions to take in an emergency situation, health information as required by 22VAC40-185-130-22VAC40-185-150, name of any additional programs or schools that the child is concurrently attending, and the first date of attendance.
5. The record for Child 5 did not contain the following information: the work phone number of each parent (an employer was listed but a work phone number was not provided), 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 (the address for the second designated person was incomplete), names of persons authorized to pick up the child, health information as required by 22VAC40-185-130-22VAC40-185-150, name of any additional programs or schools that the child is concurrently attending, and the first date of attendance.
Plan of Correction: All children's records will be completed to meet standards prior to starting.
Standard 22VAC40-185-70-A
Based on record review and discussion with staff, the center failed to ensure that the staff record for each staff person contained all of the elements as required by the standards.
Evidence:
1. The record for Staff 1 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, health information as required by 22VAC40-185-160 and 22VAC40-185-170, and information about any health problems which may interfere with fulfilling the job responsibilities.
2. The record for Staff 2 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, and information about any health problems which may interfere with fulfilling the job responsibilities.
3. The record for Staff 3 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, and information about any health problems which may interfere with fulfilling the job responsibilities.
4. The record for Staff 4 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, and information about any health problems which may interfere with fulfilling the job responsibilities.
5. The record for Staff 5 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, and information about any health problems which may interfere with fulfilling the job responsibilities.
Evidence:
1. The record for Staff 1 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, health information as required by 22VAC40-185-160 and 22VAC40-185-170, and information about any health problems which may interfere with fulfilling the job responsibilities.
2. The record for Staff 2 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, and information about any health problems which may interfere with fulfilling the job responsibilities.
3. The record for Staff 3 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, and information about any health problems which may interfere with fulfilling the job responsibilities.
4. The record for Staff 4 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, and information about any health problems which may interfere with fulfilling the job responsibilities.
5. The record for Staff 5 did not contain the following information: name, address, verification of age requirement, job title and date of employment, the name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, written information to demonstrate that the individual possesses the education, orientation training, staff development, certification and experience required by the job position, and information about any health problems which may interfere with fulfilling the job responsibilities.
Plan of Correction: All staff records will be up-to-date to meet licensing standards before employee's start. All staff records have been corrected.
Standard 22VAC40-191-60-B
Based on record review and discussion, the center failed to ensure that an employee must not be employed until the agency has the person's completed sworn statement or affirmation.
Evidence:
1. There was not a sworn statement or affirmation available for review in the record for Staff 1. Staff 6 stated that Staff 1 was hired on 08/02/2021. Staff 1 was observed working during the 10/05/2021 inspection.
2. There was not a sworn statement or affirmation available for review in the record for Staff 2. Staff 6 stated that Staff 2 was hired on 08/02/2021. Staff 2 was observed working during the 10/05/2021 inspection.
3. There was not a sworn statement or affirmation available for review in the record for Staff 3. Staff 6 stated that Staff 3 was hired on 08/02/2021. Staff 3 was observed working during the 10/05/2021 inspection.
4. There was not a sworn statement or affirmation available for review in the record for Staff 4. Staff 6 stated that Staff 4 was hired on 04/08/2021. Staff 4 was observed working during the 10/05/2021 inspection.
5. There was not a sworn statement or affirmation available for review in the record for Staff 5. Staff 6 stated that Staff 5 was hired on 08/02/2021. Staff 5 was observed working during the 10/05/2021 inspection.
Evidence:
1. There was not a sworn statement or affirmation available for review in the record for Staff 1. Staff 6 stated that Staff 1 was hired on 08/02/2021. Staff 1 was observed working during the 10/05/2021 inspection.
2. There was not a sworn statement or affirmation available for review in the record for Staff 2. Staff 6 stated that Staff 2 was hired on 08/02/2021. Staff 2 was observed working during the 10/05/2021 inspection.
3. There was not a sworn statement or affirmation available for review in the record for Staff 3. Staff 6 stated that Staff 3 was hired on 08/02/2021. Staff 3 was observed working during the 10/05/2021 inspection.
4. There was not a sworn statement or affirmation available for review in the record for Staff 4. Staff 6 stated that Staff 4 was hired on 04/08/2021. Staff 4 was observed working during the 10/05/2021 inspection.
5. There was not a sworn statement or affirmation available for review in the record for Staff 5. Staff 6 stated that Staff 5 was hired on 08/02/2021. Staff 5 was observed working during the 10/05/2021 inspection.
Plan of Correction: All sworn disclosures have been completed and placed into staff records.
Standard 22VAC40-191-60-C-2
Based on record review and discussion with the staff, the center failed to obtain the central registry findings within 30 days of employment.
1. There were no central registry search results available for review in the record for Staff 1. Staff 6 stated that Staff 1 was hired on 08/02/2021. Staff 1 was observed working during the 10/05/2021 inspection.
2. There were no central registry search results available for review in the record for Staff 3. Staff 6 stated that Staff 3 was hired on 08/02/2021. Staff 3 was observed working during the 10/05/2021 inspection.
3. There were no central registry search results available for review in the record for Staff 4. Staff 6 stated that Staff 4 was hired on 04/08/2021. Staff 4 was observed working during the 10/05/2021 inspection.
4. There were no central registry search results available for review in the record for Staff 5. Staff 6 stated that Staff 5 was hired on 08/02/2021. Staff 5 was observed working during the 10/05/2021 inspection.
1. There were no central registry search results available for review in the record for Staff 1. Staff 6 stated that Staff 1 was hired on 08/02/2021. Staff 1 was observed working during the 10/05/2021 inspection.
2. There were no central registry search results available for review in the record for Staff 3. Staff 6 stated that Staff 3 was hired on 08/02/2021. Staff 3 was observed working during the 10/05/2021 inspection.
3. There were no central registry search results available for review in the record for Staff 4. Staff 6 stated that Staff 4 was hired on 04/08/2021. Staff 4 was observed working during the 10/05/2021 inspection.
4. There were no central registry search results available for review in the record for Staff 5. Staff 6 stated that Staff 5 was hired on 08/02/2021. Staff 5 was observed working during the 10/05/2021 inspection.
Plan of Correction: All central registry paperwork has been filled out, notarized and sent to the state.
Standard 63.2(17)-1720.1-B-2
Based on record review and discussion with staff, the center failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia.
Evidence:
1. Staff 6 stated that Staff 1 was hired on 08/02/2021. The employment eligibility letter for Staff 1 was dated 09/23/2021.
2. Staff 6 stated that Staff 2 was hired on 08/02/2021. The employment eligibility letter for Staff 2 was dated 09/21/2021.
3. Staff 6 stated that Staff 3 was hired on 08/02/2021. There was not an employment eligibility letter available for review for Staff 3.
4. Staff 6 stated that Staff 5 was hired on 08/02/2021. The employment eligibility letter for Staff 5 was dated 09/21/2021.
Evidence:
1. Staff 6 stated that Staff 1 was hired on 08/02/2021. The employment eligibility letter for Staff 1 was dated 09/23/2021.
2. Staff 6 stated that Staff 2 was hired on 08/02/2021. The employment eligibility letter for Staff 2 was dated 09/21/2021.
3. Staff 6 stated that Staff 3 was hired on 08/02/2021. There was not an employment eligibility letter available for review for Staff 3.
4. Staff 6 stated that Staff 5 was hired on 08/02/2021. The employment eligibility letter for Staff 5 was dated 09/21/2021.
Plan of Correction: All fingerprints will be obtained and placed in staff records. In the future all fingerprints will be done prior to hire.