Inspection · 2022-04-08
Date
2022-04-08
Complaint Related
Yes
Licensing Inspector
Lauren Bickford
(540) 280-0742
(540) 280-0742
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
The licensing inspector conducted an unannounced complaint inspection in response to complaints received by the department on 03/08/2022 and 04/08/2022 regarding ratios, staff qualifications, and the supervision of children. The investigation was initiated on April 8, 2022 and completed on September 26, 2022. On April 11, 2022, the licensing inspector conducted an unannounced inspection from approximately 11:55am to 2:30pm. Interviews were completed, observations were made at the center, and documentation was reviewed. On September 8, 2022, the inspector was on site from approximately 9:20am to 11:40am conducting additional interviews and reviewing documentation. The preponderance of evidence gathered during the investigation supports the allegations, therefore the complaint is determined to be valid. See the violation notice for more details.
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 the date of receipt. You should 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 stand(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).
Violations
7Standard 8VAC20-770-60-B
Based on a review of one staff record, the center did not obtain a completed sworn statement or affirmation within the required timeframe.
Evidence:
The sworn statement in the record for Staff #1, employed 05/28/21, was dated 06/01/21. A sworn statement is required to be obtained prior to employment.
Evidence:
The sworn statement in the record for Staff #1, employed 05/28/21, was dated 06/01/21. A sworn statement is required to be obtained prior to employment.
Plan of Correction: Per the Center: "Center director will ensure that all sworn disclosures will not be signed before the first day of employment."
Standard 8VAC20-780-350-B-1
Based on observation, a review of documentation, and information obtained during interviews, the center did not maintain the staff-to-children ratios for children birth up to 16 months of age.
Evidence:
1) A sample of attendance records for the Infant A and Infant B classrooms were reviewed. The attendance records revealed the Infant A classroom was out of ratio on six out of ten days reviewed from 03/28/22 through 04/08/22. The attendance records showed the Infant B classroom was out of ratio on nine out of ten days reviewed from 03/28/22 through 04/08/22.
2) The staff interviewed reported that on average three to four days a week the Infant A and Infant B classrooms are out of ratio by one to two children throughout the day. The youngest child in the Infant A classroom is 4.5 months old and the youngest child in the Infant B classroom is 6 months old.
3) During the inspection on 04/11/22, the inspector observed five children in the care of one staff member in the Infant A classroom. The youngest child was 4.5 months old.
The applicable staff-to-child ratio for children birth up to 16 months of age is one staff member for every four children.
Evidence:
1) A sample of attendance records for the Infant A and Infant B classrooms were reviewed. The attendance records revealed the Infant A classroom was out of ratio on six out of ten days reviewed from 03/28/22 through 04/08/22. The attendance records showed the Infant B classroom was out of ratio on nine out of ten days reviewed from 03/28/22 through 04/08/22.
2) The staff interviewed reported that on average three to four days a week the Infant A and Infant B classrooms are out of ratio by one to two children throughout the day. The youngest child in the Infant A classroom is 4.5 months old and the youngest child in the Infant B classroom is 6 months old.
3) During the inspection on 04/11/22, the inspector observed five children in the care of one staff member in the Infant A classroom. The youngest child was 4.5 months old.
The applicable staff-to-child ratio for children birth up to 16 months of age is one staff member for every four children.
Plan of Correction: Per the Center: "Center director has hired new staff members and made adjustments to employee schedules to ensure that correct ratios are being followed. Students in the infant B class are mobile before entering into the infant B classroom. Students will be 12 months before entering into the infant B classroom."
Standard 8VAC20-780-350-B-2
Based on a review of documentation and information obtained during interviews, the center did not maintain the staff-to-children ratio for children 16 months up to 24 months.
Evidence: 1) Staff interviewed reported that on 04/08/22, the Toddler classroom was out of ratio by one child during the day. 2) The attendance record reviewed for 04/08/22 showed the Toddler classroom had one staff member to six children from approximately 9:30am until 12:30pm. The age of the youngest child in the Toddler classroom is 16 months.
The applicable staff-to-child ratio for children 16 months up to 24 months is one staff member for every five children.
Evidence: 1) Staff interviewed reported that on 04/08/22, the Toddler classroom was out of ratio by one child during the day. 2) The attendance record reviewed for 04/08/22 showed the Toddler classroom had one staff member to six children from approximately 9:30am until 12:30pm. The age of the youngest child in the Toddler classroom is 16 months.
The applicable staff-to-child ratio for children 16 months up to 24 months is one staff member for every five children.
Plan of Correction: Per the Center: "Staff have been hired and adjustments to employees schedules have been in effect to ensure that all child to staff ratios are in compliance."
Standard 8VAC20-780-350-C
Based on observation, a review of documentation and information obtained during interviews, the center did not ensure that when children are regularly in ongoing mixed age groups, the staff-to-children ratio applicable to the youngest child in the group shall apply to the entire group.
Evidence:
1) During the inspection on 04/11/22, the inspector observed ten children in the care of one staff member in the Preppers classroom.
2) The staff interviewed reported the ages of the children in the Preppers classroom range from 2 years 6 months to 3 years old and the children are regularly combined. The applicable staff-to-child ratio for two-year-old children is one staff for every eight children.
Evidence:
1) During the inspection on 04/11/22, the inspector observed ten children in the care of one staff member in the Preppers classroom.
2) The staff interviewed reported the ages of the children in the Preppers classroom range from 2 years 6 months to 3 years old and the children are regularly combined. The applicable staff-to-child ratio for two-year-old children is one staff for every eight children.
Plan of Correction: Per the Center: "Children 3 years and older have transitioned out of the Prepper classroom. Schedule changes have taken effect for staff to ensure that child staff ratio is in compliance."
Standard 8VAC20-780-530-A-1
Based on observation, a review of documentation and interview, the center did not ensure at least one staff in each classroom or area where children are present should have current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children
in care.
Evidence:
1) During the inspection on 04/11/22, Staff #1, employed on 05/28/21, was observed providing transportation to children in care. 2) During interview, Staff #2 reported Staff #1 was assisting with transportation that week. Staff #2 was not sure if Staff #1 had current CPR certification. 3) The record for Staff #1 did not contain documentation that the staff had current CPR certification. Staff #1 was the only staff member present with the children during transportation on 04/11/22.
in care.
Evidence:
1) During the inspection on 04/11/22, Staff #1, employed on 05/28/21, was observed providing transportation to children in care. 2) During interview, Staff #2 reported Staff #1 was assisting with transportation that week. Staff #2 was not sure if Staff #1 had current CPR certification. 3) The record for Staff #1 did not contain documentation that the staff had current CPR certification. Staff #1 was the only staff member present with the children during transportation on 04/11/22.
Plan of Correction: Per the Center: "Staff member is no longer on transportation. If need staff member will resume transportation on a as needed basis once scheduled CPR occurs on 10/26/2022 is completed."
Standard 8VAC20-780-530-A-2
Based on observation, a review of documentation and interview, the center did not ensure at least one staff in each classroom or area where children are present should have current certification in first aid.
Evidence:
1) During the inspection on 04/11/22, Staff #1, employed 05/28/21, was observed providing transportation to children in care. 2) During interview, Staff #2 reported Staff #1 was assisting
with transportation that week. Staff #2 was not sure if Staff #1 had current certification in first aid. 3) The record for Staff #1 did not contain documentation that the staff had current certification in first aid. Staff #1 was the only staff member present with the children during transportation on 04/11/22.
Evidence:
1) During the inspection on 04/11/22, Staff #1, employed 05/28/21, was observed providing transportation to children in care. 2) During interview, Staff #2 reported Staff #1 was assisting
with transportation that week. Staff #2 was not sure if Staff #1 had current certification in first aid. 3) The record for Staff #1 did not contain documentation that the staff had current certification in first aid. Staff #1 was the only staff member present with the children during transportation on 04/11/22.
Plan of Correction: Per the Center: "Staff has been removed from transportation and is on a as needed basis once completion of CPR first aid scheduled for 10/26/22."
Standard 8VAC20-780-70
Based on a review of one staff record and interview, the center did not ensure one staff record contained all the required information.
Evidence:
1) The record for Staff #1, employed 05/28/21, did not contain the following information:
a) Documentation that two or more references as to character and reputation as well as competency were checked before employment.
b) Documentation to demonstrate that the individual possesses orientation and training
c) The tuberculosis (TB) screening results in the record were dated 01/25/22. Staff hired prior to 10/13/21 were required to obtain TB results within 21 days of beginning employment and such documentation was to be retained in the staff record.
2) During interview, Staff #2 reported the missing documentation was not available for review during the inspections conducted on 04/11/22 and 09/08/22.
Evidence:
1) The record for Staff #1, employed 05/28/21, did not contain the following information:
a) Documentation that two or more references as to character and reputation as well as competency were checked before employment.
b) Documentation to demonstrate that the individual possesses orientation and training
c) The tuberculosis (TB) screening results in the record were dated 01/25/22. Staff hired prior to 10/13/21 were required to obtain TB results within 21 days of beginning employment and such documentation was to be retained in the staff record.
2) During interview, Staff #2 reported the missing documentation was not available for review during the inspections conducted on 04/11/22 and 09/08/22.
Plan of Correction: Per the Center: "Reference checks were completed on Staff #1 by the owners of [LLC], the franchise of The Learning Experience.
Orientation documentation has been received. Center director will ensure that all orientation documentation is completed in the correct time frame and filed correctly. Center director will ensure that all TB screenings will not be dated within 21 days of beginning employment."
Orientation documentation has been received. Center director will ensure that all orientation documentation is completed in the correct time frame and filed correctly. Center director will ensure that all TB screenings will not be dated within 21 days of beginning employment."