Inspection · 2024-08-26
Date
2024-08-26
Complaint Related
No
Licensing Inspector
Christina Jones
(540) 340-2672
(540) 340-2672
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 (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
32.1 Report by person other than physician
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced, on-site renewal inspection was initiated on 8/26/2024 and completed on 8/26/2024. The on-site inspection began at 9:40am and ended at 12:45PM. The inspector reviewed compliance in the areas listed above. There were 108 children present and 20 staff. The inspector reviewed 5 children?s records and 5 staff records on-site on 8/26/2024. 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 9/10/2024. A POC submitted after this date will not appear on the public website.
Violations
10Standard 22.1-289.035-B-4
Based on review of five staff records, the center did not obtain the results of an out-of-state central registry check within 30 days of employment and an out-of-state sex offender registry search prior to employment from all states in which staff members have resided within the last five years prior to employment.
Evidence: The record for Staff #2 (Date of hire: 3/13/2023) disclosed that they had resided in outside of Virginia within the past 5 years. The record did not contain documentation of a completed out-of-state central registry check within 30 days of employment nor a out-of-state sex offender registry search prior to employment from all states where they resided within the last five years prior to employment.
Evidence: The record for Staff #2 (Date of hire: 3/13/2023) disclosed that they had resided in outside of Virginia within the past 5 years. The record did not contain documentation of a completed out-of-state central registry check within 30 days of employment nor a out-of-state sex offender registry search prior to employment from all states where they resided within the last five years prior to employment.
Plan of Correction: Staff file is now up to date. Management will ensure out of state background checks are conducted during the hiring process.
Standard 8VAC20-780-245-A
Based on documentation and staff interview, the center did not ensure that staff complete annually a minimum of 16 hours of training appropriate to the age of the children in care.
Evidence:
1. The record for Staff 1 only had documentation showing 8.5 hours of annual training completed from July 2023-July 2024.
2. The record for Staff 2 only had documentation showing 8.5 hours of annual training completed from July 2023-July 2024.
3. The record for Staff 3 only had documentation showing 8.5 hours of annual training completed from July 2023-July 2024.
Evidence:
1. The record for Staff 1 only had documentation showing 8.5 hours of annual training completed from July 2023-July 2024.
2. The record for Staff 2 only had documentation showing 8.5 hours of annual training completed from July 2023-July 2024.
3. The record for Staff 3 only had documentation showing 8.5 hours of annual training completed from July 2023-July 2024.
Plan of Correction: Staff training documents will be updated yearly. Copies of trainings will be added to file directly after trainings.
Standard 8VAC20-780-260-A
Based on review of documentation, the center did not ensure they have an annual fire inspection report from the appropriate fire official.
Evidence: The last fire inspection report on file at the center was completed on 6/1/2022.
Evidence: The last fire inspection report on file at the center was completed on 6/1/2022.
Plan of Correction: Inspection report are not given directly to school on day of inspection, so management will ensure that within a week of inspection reach out to EMCOR for inspection reports.
Standard 8VAC20-780-270-A
Based on observation, the center did not ensure that all areas and equipment of the center, inside and outside, were maintained in a clean, safe, and operable condition.
Evidence: The potty seat that was in the Two?s classroom bathroom had a handle that was broken off exposing sharp edges on the side.
Evidence: The potty seat that was in the Two?s classroom bathroom had a handle that was broken off exposing sharp edges on the side.
Plan of Correction: The potty seat has been removed from the two's classroom. The seats will no longer be used.
Standard 8VAC20-780-340-D
Based on interviews and documentation review, the center failed to ensure that each grouping of children had at least one staff member that met the qualifications of program leader or program director regularly present.
Evidence:
The records for staff #1 and staff #2 did not have documentation to demonstrate how staff #1 and staff #2 meet program leader qualifications. Both staff were confirmed as lead teachers for their classrooms.
Evidence:
The records for staff #1 and staff #2 did not have documentation to demonstrate how staff #1 and staff #2 meet program leader qualifications. Both staff were confirmed as lead teachers for their classrooms.
Plan of Correction: Staff 1 and 2 will obtain trainings for lead qualification and obtain this status for the duration of their employment no later than October 15, 2024.
Standard 8VAC20-780-350-B-2
Based on observation, the center did not maintain the required supervision ratio of staff to children whenever children are in care.
Evidence: During the inspection, the center did not maintain the required supervision ratio of 1 staff for every 5 children in the Toddler?s classroom where the youngest child was age 22 months. There were 2 staff observed with 12 children on the playground.
Evidence: During the inspection, the center did not maintain the required supervision ratio of 1 staff for every 5 children in the Toddler?s classroom where the youngest child was age 22 months. There were 2 staff observed with 12 children on the playground.
Plan of Correction: Parental consent & developmental assessments will be required and obtained for children moving to a different ratio or appropriate teacher to child ratio will be enforced.
Standard 8VAC20-780-420-E-3
Based on review of 5 child records, the center did not ensure annually that parent confirmation of the required information in the child record is up to date.
Evidence:
1. Child 1 did not have documentation that their parent had confirmed the updated record annually. The last signature was dated 8/7/2023.
2. Child 2 did not have documentation that their parent had confirmed the updated record annually. The last signature was dated 3/6/2023.
3. Child 3 did not have documentation that their parent had confirmed the updated record annually. The last signature was dated 7/6/2021.
4. Child 4 did not have documentation that their parent had confirmed the updated record annually. The last signature was dated 6/8/2022.
Evidence:
1. Child 1 did not have documentation that their parent had confirmed the updated record annually. The last signature was dated 8/7/2023.
2. Child 2 did not have documentation that their parent had confirmed the updated record annually. The last signature was dated 3/6/2023.
3. Child 3 did not have documentation that their parent had confirmed the updated record annually. The last signature was dated 7/6/2021.
4. Child 4 did not have documentation that their parent had confirmed the updated record annually. The last signature was dated 6/8/2022.
Plan of Correction: Parents will verify child files yearly and update information as needed. Parents will initial once documents are up to date by October 2024.
Standard 8VAC20-780-500-B
Based on observation, the center did not ensure that the surface for diapering was non-absorbent.
Evidence: In the Two?s classroom, the diapering pad was ripped in the center causing the surface to not be non-absorbent as required.
Evidence: In the Two?s classroom, the diapering pad was ripped in the center causing the surface to not be non-absorbent as required.
Plan of Correction: Management coached staff on state regulations and set expectation for staff to inform management of safety hazards observed including rips or tears in diaper changing pad. Management will ensure that diapering pads are checked quarterly for any rips or tears. Pad will be replaced immediately.
Standard 8VAC20-780-510-P
Based on review of 6 medications and medication authorizations, the center did not ensure they notify parents of expired medication authorization and dispose of any medication that parents do not pick up after 14 days of notification.
Evidence: The documentation that was on file for Child 2?s medication had parent and physician authorization that expired on 3/13/2024.
Evidence: The documentation that was on file for Child 2?s medication had parent and physician authorization that expired on 3/13/2024.
Plan of Correction: A medication spreadsheet will be created with expiration dates for all students and dates when medication should be updated in order to give parents time to get required documents and medication.
Standard 8VAC20-780-70
Based on review of five staff records, the center did not obtain all of the required documentation for staff records.
Evidence:The center did not have documentation for Staff #2 (Date of hire:3/13/2023) Staff #3 (Date of hire: 7/1/2024) and Staff 4 (Date of hire: 7/8/2024), that two or more references as to character and reputation as well as competency were checked before employment.
Evidence:The center did not have documentation for Staff #2 (Date of hire:3/13/2023) Staff #3 (Date of hire: 7/1/2024) and Staff 4 (Date of hire: 7/8/2024), that two or more references as to character and reputation as well as competency were checked before employment.
Plan of Correction: Reference checks will be conducted before employee begins work.