Inspection · 2023-05-02
Date
2023-05-02
Complaint Related
No
Licensing Inspector
Molly Muscat
(804) 588-2367
(804) 588-2367
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
Inspector Notes
An unannounced inspection was conducted on May 2, 2023 from approximately 1:00 pm to 2:00 pm in response to a self-reported incident in reference to supervision that was received on April 19, 2023. Documentation was gathered and reviewed while at the center as well as electronically. A follow up meeting was held with local agency on 05/05/2023. Interviews were conducted while at the center in conjunction with local agency.
The preponderance of evidence gathered during the investigation supports violation of standards in regard to the self-report.
Violations were issued as a result of this investigation.
Violations
5Standard 8VAC20-780-270-A
Based on interviews, and documentation review, the center failed to ensure that areas and equipment of the center, inside and outside, shall be maintained in a clean, safe, and operable condition. Evidence:
1) Interviews with staff #1, staff #2, staff #3, staff #4, and the Director revealed that the two gates on the playground were not operating properly.
2) Review of the ?Daily Playground Inspection? checklist dated for the week of April 17th indicated that the gates were not latching properly.
3) The Director confirmed that a work order was put in to fix the gates on April 15th.
1) Interviews with staff #1, staff #2, staff #3, staff #4, and the Director revealed that the two gates on the playground were not operating properly.
2) Review of the ?Daily Playground Inspection? checklist dated for the week of April 17th indicated that the gates were not latching properly.
3) The Director confirmed that a work order was put in to fix the gates on April 15th.
Plan of Correction: Per the center "gate has been fixed. Continue to complete playground safety check list to ensure that all gates and locks are noted when not working properly, so that it can be corrected immediately."
Standard 8VAC20-780-340-A
Based on interviews, and documentation review, the center failed to ensure that when staff are supervising children, they shall always ensure their care, protection, and guidance. Evidence: Interviews with staff #1, staff #2, staff #3, staff #4, staff #5, and the Director, and documentation review of Child Supervision (CSR Name to Face) tracking sheets of classroom #1, classroom #2, and classroom #3 revealed that on the morning of 4/19/23 two toddler children walked through one gate located on the toddler playground, down a corridor on the side of the building, through another gate located on the preschool playground and were found alone on the preschool playground on equipment designed for children age 2-4 years old. The children were unsupervised for approximately 13 minutes.
Plan of Correction: Per the center "staff retrained on CSR recording and implementation on 04/25/23. Staff retrained on playground safety and supervision on 05/11/23. Director and AD to continue to monitor CSR accuracy and transitions. Director and AD to continue to monitor outside time and playground utilization."
Standard 8VAC20-780-340-F
Based on documentation review, and interviews, the center failed to ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff. Evidence:
1) Review of Child Supervision (CSR Name to Face) tracking sheet revealed that classroom #1, with a group of 11 toddlers and 2 staff, went outside to the toddler playground at approximately 9:40 am.
2) Interview with staff #5, revealed that she found two toddler children, alone on the preschool playground at approximately 9:53 am while she was taking her class outside to play. Staff #5 brought the two toddler children back to the toddler class on the toddler playground.
3) Review of Child Supervision (CSR Name to Face) tracking sheet revealed that classroom #3 went outside at approximately 9:53 am.
4) Interviews with staff #1, staff #2, staff #3, and staff #4 revealed that staff #5 brought the two toddlers back to the toddler playground at approximately 9:54 am.
5) The Director confirmed that the two toddler children were out of sight and sound supervision for approximately 13 minutes.
1) Review of Child Supervision (CSR Name to Face) tracking sheet revealed that classroom #1, with a group of 11 toddlers and 2 staff, went outside to the toddler playground at approximately 9:40 am.
2) Interview with staff #5, revealed that she found two toddler children, alone on the preschool playground at approximately 9:53 am while she was taking her class outside to play. Staff #5 brought the two toddler children back to the toddler class on the toddler playground.
3) Review of Child Supervision (CSR Name to Face) tracking sheet revealed that classroom #3 went outside at approximately 9:53 am.
4) Interviews with staff #1, staff #2, staff #3, and staff #4 revealed that staff #5 brought the two toddlers back to the toddler playground at approximately 9:54 am.
5) The Director confirmed that the two toddler children were out of sight and sound supervision for approximately 13 minutes.
Plan of Correction: Per the center "staff retrained on CSR recording and implementation on 04/25/23. Staff retrained on playground safety and supervision on 05/11/23."
Standard 8VAC20-780-350-B-2
Based on documentation review, and interviews, the center failed to follow the staff-to-children ratio for toddlers of 1 staff to 5 children. Evidence:
1) Review of Child Supervision (CSR Name to Face) tracking sheets revealed that on the morning of 04/19/2023 classroom #1, with children aged 16 months to 2 years, was out of ratio for approximately 22 minutes.
2) Review of Child Supervision (CSR Name to Face) tracking sheet for Classroom #2, with children aged 16 months to 2 years, revealed that it was out of ratio for approximately 6 minutes.
3) The Director confirmed that classroom #1 was out of ratio for approximately 22 minutes and classroom #2 was out of ratio for approximately 6 minutes.
1) Review of Child Supervision (CSR Name to Face) tracking sheets revealed that on the morning of 04/19/2023 classroom #1, with children aged 16 months to 2 years, was out of ratio for approximately 22 minutes.
2) Review of Child Supervision (CSR Name to Face) tracking sheet for Classroom #2, with children aged 16 months to 2 years, revealed that it was out of ratio for approximately 6 minutes.
3) The Director confirmed that classroom #1 was out of ratio for approximately 22 minutes and classroom #2 was out of ratio for approximately 6 minutes.
Plan of Correction: Per the center "staff retrained on student to teacher ratio and policy on how to respond when out of ratio. Director and AD to ensure that staffing and scheduling is adequate."
Standard 8VAC20-780-40-E
Based on documentation review, and interview, the center failed to ensure that the center?s own policies and procedures are followed. Evidence:
1) Review of the centers ?Playground Safety? policy states ?supervision with appropriate staff/child ratios is maintained at all times while on the playground.? It also states ?name to face attendance using the CSR is conducted on a regular basis so that every child is accounted for at all times.?
2) Interviews with staff #1, staff #2, staff #3, staff #4, and the Director revealed that there were 16 children ages 16 months to 2 years with 3 staff outside on the playground. The ratio for this age group is 1 staff to 5 children.
3) Review of the ?Child Supervision Record (CSR) standard operating procedures states ?as children arrive, one of the teachers in the room should sign them in by writing their full legal name and age. This should be done as soon as the child enters the classroom.? It also states ?when transitioning from one location to another, teachers will use the name-to-face transitions section of the CSR to confirm all children are accounted for.?
4) Review of Child Supervision (CSR Name to Face) tracking sheets revealed that on 04/19/23 classroom #2 signed two children out of the CSR and sent them to classroom #1 at approximately 9:18 am. Review of the CSR for classroom #1 did not show that the 2 children were signed in.
5) Review of the Child Supervision (CSR Name to Face tracking sheet revealed that classroom #1 transitioned outside at 9:40 am. Review of the CSR for classroom #2 did not show the transition outside. Interview with staff #1, staff #2, and staff #3, revealed that classroom #2 went outside at approximately 9:45 am.
6) Review of the ?playground schedule? indicated that classroom #1 has an assigned outside time of 10:30-11:00 and that classroom #2 has an assigned outside time of 11:00-11:30. Interviews with staff and the Director revealed that the classes are not allowed to go outside together and that only one class at a time is allowed on the playground. Documentation review and interviews revealed that both classes went outside prior to their assigned time and were on the playground at the same time.
1) Review of the centers ?Playground Safety? policy states ?supervision with appropriate staff/child ratios is maintained at all times while on the playground.? It also states ?name to face attendance using the CSR is conducted on a regular basis so that every child is accounted for at all times.?
2) Interviews with staff #1, staff #2, staff #3, staff #4, and the Director revealed that there were 16 children ages 16 months to 2 years with 3 staff outside on the playground. The ratio for this age group is 1 staff to 5 children.
3) Review of the ?Child Supervision Record (CSR) standard operating procedures states ?as children arrive, one of the teachers in the room should sign them in by writing their full legal name and age. This should be done as soon as the child enters the classroom.? It also states ?when transitioning from one location to another, teachers will use the name-to-face transitions section of the CSR to confirm all children are accounted for.?
4) Review of Child Supervision (CSR Name to Face) tracking sheets revealed that on 04/19/23 classroom #2 signed two children out of the CSR and sent them to classroom #1 at approximately 9:18 am. Review of the CSR for classroom #1 did not show that the 2 children were signed in.
5) Review of the Child Supervision (CSR Name to Face tracking sheet revealed that classroom #1 transitioned outside at 9:40 am. Review of the CSR for classroom #2 did not show the transition outside. Interview with staff #1, staff #2, and staff #3, revealed that classroom #2 went outside at approximately 9:45 am.
6) Review of the ?playground schedule? indicated that classroom #1 has an assigned outside time of 10:30-11:00 and that classroom #2 has an assigned outside time of 11:00-11:30. Interviews with staff and the Director revealed that the classes are not allowed to go outside together and that only one class at a time is allowed on the playground. Documentation review and interviews revealed that both classes went outside prior to their assigned time and were on the playground at the same time.
Plan of Correction: Per the center "staff retrained on CSR recording and implementation on 04/25/23. Staff retrained on playground safety and supervision on 05/11/23. Director and AD to continue to monitor CSR accuracy and transitions."