Inspection · 2024-08-20
Date
2024-08-20
Complaint Related
No
Licensing Inspector
Heather Dapper
(804) 625-2304
(804) 625-2304
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced, on-site focused inspection was initiated on August 20, 2024 and completed on August 27, 2024, as a part of provisional licensure period. The on-site inspection began at 4:00 PM and ended at 5:58 PM. The inspector reviewed compliance in the areas listed above. There were 14 children present. The inspector reviewed five children?s records and three staff records electronically on August 22, 2024, and August 27, 2024 . This inspection included document review, tour of the facility, interviews, and observations.
Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on September 4, 2024. A POC submitted after this date will not appear on the public website.
This inspection report was amended on 11/12/2024 and 11/25/2024.
Violations
15Standard 22.1-289.011-F
Based on observation and interviews, it was determined that the facility did not ensure the license and any other documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.
Evidence:
1. The Provisional license was not posted.
2. The most recent inspection summary (3/07/2024) was not posted.
3. Staff #2 did not know where the license or inspections were located.
Evidence:
1. The Provisional license was not posted.
2. The most recent inspection summary (3/07/2024) was not posted.
3. Staff #2 did not know where the license or inspections were located.
Plan of Correction: We will post the license summary in plain site.
Standard 8VAC20-780-130-A
REPEAT VIOLATION, SYSTEMIC VIOLATION
Based on a review of children's records and interview, the center did not ensure that each child's record contained documentation of immunizations required by the State Board of Health before the child can attend the center.
Evidence:
1. The records for child #1 (enrolled 8/20/24), child #2 (enrolled 8/19/2024), child #3 (enrolled 8/19/2024), child #4 (enrolled 8/19/2024), and child #5 (enrolled 8/19/2024) did not have documentation of immunizations.
2. Staff #2 stated that the child records were at another center.
Based on a review of children's records and interview, the center did not ensure that each child's record contained documentation of immunizations required by the State Board of Health before the child can attend the center.
Evidence:
1. The records for child #1 (enrolled 8/20/24), child #2 (enrolled 8/19/2024), child #3 (enrolled 8/19/2024), child #4 (enrolled 8/19/2024), and child #5 (enrolled 8/19/2024) did not have documentation of immunizations.
2. Staff #2 stated that the child records were at another center.
Plan of Correction: 1. Copies of child records were made and brought to school.
2. We will keep copies of all child record at both locations.
3. Director/ Coordinator
2. We will keep copies of all child record at both locations.
3. Director/ Coordinator
Standard 8VAC20-780-140-A
REPEAT VIOLATION, SYSTEMIC VIOLATION
Based on a review of children's records, the center did not ensure that each child shall have a physical examination by or under the direction of a physician before the child's attendance or within one month after attendance.
Evidence:
1. The records for child #1 (enrolled 8/20/24), child #2 (enrolled 8/19/2024), child #3 (enrolled 8/19/2024), child #4 (enrolled 8/19/2024), and child #5 (enrolled 8/19/2024) did not have documentation of a physical examination.
2. Staff #2 stated that the child records were at another center.
Based on a review of children's records, the center did not ensure that each child shall have a physical examination by or under the direction of a physician before the child's attendance or within one month after attendance.
Evidence:
1. The records for child #1 (enrolled 8/20/24), child #2 (enrolled 8/19/2024), child #3 (enrolled 8/19/2024), child #4 (enrolled 8/19/2024), and child #5 (enrolled 8/19/2024) did not have documentation of a physical examination.
2. Staff #2 stated that the child records were at another center.
Plan of Correction: 1. Copies of child records were made & brought to school
2. We will keep copies of all child records at both locations.
3. Director/Coordinator
2. We will keep copies of all child records at both locations.
3. Director/Coordinator
Standard 8VAC20-780-240-B
Based on a record review, the facility did not ensure that staff received all required training by the end of their first day of assuming job responsibilities.
Evidence:
The record for staff #2 (employed 4/30/2024) did not have documentation of orientation training. The record contained a blank copy of the orientation training, staff #2 did not initial or sign that the training was completed.
Evidence:
The record for staff #2 (employed 4/30/2024) did not have documentation of orientation training. The record contained a blank copy of the orientation training, staff #2 did not initial or sign that the training was completed.
Plan of Correction: We will include documentation of orientation in staff files.
Standard 8VAC20-780-245-L
Based on record review, the center failed to have at least one staff member on duty who obtained instruction in performing the daily health observation of children within the last three years.
Evidence:
1. The records for staff #1 (employed 6/10/24) and staff #2 (employed 4/30/24) did not have documentation of daily health observation training.
Evidence:
1. The records for staff #1 (employed 6/10/24) and staff #2 (employed 4/30/24) did not have documentation of daily health observation training.
Plan of Correction: We will include documentation of orientation in staff files.
Standard 8VAC20-780-340-C
Based on observation and interviews, the center did not ensure that during the stated hours of operation, there always shall be on the premises when one or more children are present, one staff member who meets the qualifications of a program leader or program director and an immediately available staff member, volunteer or other employee who is at least 16 years of age, with direct means for communication between the two of them.
Evidence:
1. From approximately 5:06 PM to 5:58 PM, one staff member was observed working alone. Staff #1 acknowledged that she was working alone.
2 The record for staff #1 (employed 6/10/24) did not have documentation that staff #1 meets the qualifications of a program leader or program director.
3 Administration acknowledged that staff #1 was working alone from approximately 5:06 PM. to 5:58 PM.
Evidence:
1. From approximately 5:06 PM to 5:58 PM, one staff member was observed working alone. Staff #1 acknowledged that she was working alone.
2 The record for staff #1 (employed 6/10/24) did not have documentation that staff #1 meets the qualifications of a program leader or program director.
3 Administration acknowledged that staff #1 was working alone from approximately 5:06 PM. to 5:58 PM.
Plan of Correction: 1. 2 staff member will be scheduled at tall times.
2. Going forward there will always be 2 staff members working w/ the children.
3. Director
2. Going forward there will always be 2 staff members working w/ the children.
3. Director
Standard 8VAC20-780-430-K
Based on observation, the center failed to make provision for an individual place for each child's belongings.
Evidence:
1. Eleven backpacks, three lunch containers, and two water bottles were on the floor.
2. Staff #2 and staff #3 reported that the center did not have an individual place for each child?s belongings.
Evidence:
1. Eleven backpacks, three lunch containers, and two water bottles were on the floor.
2. Staff #2 and staff #3 reported that the center did not have an individual place for each child?s belongings.
Plan of Correction: We will provide baskets for children's belongings.
Standard 8VAC20-780-530-A-1
REPEAT VIOLATION
Based on record review, the center did not ensure at least one staff in each classroom or area where children are present had a current Cardiopulmonary resuscitation (CPR) certification.
Evidence:
The record for staff #1 (employed 6/10/24) did not have current CPR certification. Staff #1 was alone with a group of children from 5:06 PM to 5:58 PM on 8/20/2024.
Based on record review, the center did not ensure at least one staff in each classroom or area where children are present had a current Cardiopulmonary resuscitation (CPR) certification.
Evidence:
The record for staff #1 (employed 6/10/24) did not have current CPR certification. Staff #1 was alone with a group of children from 5:06 PM to 5:58 PM on 8/20/2024.
Plan of Correction: 1. Added staff #1's CPR card to the file.
2. Make sure all staff have CPR cards in files.
3. Director
2. Make sure all staff have CPR cards in files.
3. Director
Standard 8VAC20-780-530-A-2
REPEAT VIOLATION
Based on record review, the center did not ensure at least one staff in each classroom or area where children are present had a current first aid certification.
Evidence:
The record for staff #1 (employed 6/10/24) did not have current first aid certification. Staff #1 was alone with a group of children from 5:06 PM to 5:58 PM on 8/20/2024.
Based on record review, the center did not ensure at least one staff in each classroom or area where children are present had a current first aid certification.
Evidence:
The record for staff #1 (employed 6/10/24) did not have current first aid certification. Staff #1 was alone with a group of children from 5:06 PM to 5:58 PM on 8/20/2024.
Plan of Correction: Director will schedule at least two staff members during open hours. Director will ensure all staff have current CPR certifications.
Standard 8VAC20-780-540-C
REPEAT VIOLATION, SYSTEMIC VIOLATION
Based on observation and interview, the first aid kit did not contain the minimum required supplies.
Evidence:
1. There was not a first aid kit at the center.
2. Staff #2 did not know where the first aid kit was located or if there was one at the center.
Based on observation and interview, the first aid kit did not contain the minimum required supplies.
Evidence:
1. There was not a first aid kit at the center.
2. Staff #2 did not know where the first aid kit was located or if there was one at the center.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-540-E
REPEAT VIOLATION, SYSTEMIC VIOLATION
Based on observation and interviews, the center did not have all nonmedical emergency supplies as required.
Evidence:
1. There was no battery-operated radio or battery-operated flashlight at the center.
2. Staff #2 did not know where the nonmedical emergency supplies were at the center and was unable to find the supplies during the inspection.
Based on observation and interviews, the center did not have all nonmedical emergency supplies as required.
Evidence:
1. There was no battery-operated radio or battery-operated flashlight at the center.
2. Staff #2 did not know where the nonmedical emergency supplies were at the center and was unable to find the supplies during the inspection.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-C
Based on observations and discussion with the staff, the facility failed to ensure that emergency evacuation and shelter-in-place procedures/maps shall be posted in a location conspicuous to staff and children on each floor of the building.
Evidence:
1. Emergency evacuation and shelter-in-place procedures/maps were not posted.
2. Staff #2 did not know where the emergency evacuation or shelter-in-place procedures/maps were located.
Evidence:
1. Emergency evacuation and shelter-in-place procedures/maps were not posted.
2. Staff #2 did not know where the emergency evacuation or shelter-in-place procedures/maps were located.
Plan of Correction: We will post emergency evacuation and shelter in place procedures.
Standard 8VAC20-780-550-I
Based on observation, the center failed to ensure that a 911 or local dial number for police, fire and emergency medical services and the number of the regional poison control center shall be posted in a visible place.
Evidence:
1. The phone numbers for 991 or local police/ fire and poison control were not posted in any visible place at the center.
2. Staff #2 acknowledged that the emergency information was not posted at the center.
Evidence:
1. The phone numbers for 991 or local police/ fire and poison control were not posted in any visible place at the center.
2. Staff #2 acknowledged that the emergency information was not posted at the center.
Plan of Correction: We will post emergency numbers in plain site.
Standard 8VAC20-780-60-A
REPEAT VIOLATION, SYSTEMIC VIOLAITON
Based on a review of children's records and interview, the center did not ensure that each record contains all required information.
Evidence:
1. The record for child #4 did not have one of the two designated people to call in an emergency.
2. The record for child #5 did not have two of the two designated people to call in an emergency.
Based on a review of children's records and interview, the center did not ensure that each record contains all required information.
Evidence:
1. The record for child #4 did not have one of the two designated people to call in an emergency.
2. The record for child #5 did not have two of the two designated people to call in an emergency.
Plan of Correction: 1. Added emergency contacts to file.\
2. Will ensure all child files have 2 contacts.
3. Coordinator
2. Will ensure all child files have 2 contacts.
3. Coordinator
Standard 8VAC20-780-90-A
Based on a review of children's record, the center did not obtain a written agreement between the parent and the center by the first day of the child's attendance that was signed by the parent.
Evidence:
1. The records for child #1, child #2, child #3, child #4, and child #5 did not have documentation of written parental agreements.
Evidence:
1. The records for child #1, child #2, child #3, child #4, and child #5 did not have documentation of written parental agreements.
Plan of Correction: We will obtain written agreements for all children