Inspection · 2022-01-10
Date
2022-01-10
Complaint Related
No
Licensing Inspector
Maria Robles-Lopez
(703) 397-3827
(703) 397-3827
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.
8VAC20-770 Background Checks (22VAC40-191)
Inspector Notes
An unannounced monitoring inspection was conducted on 01/12/2021 to monitor the program?s compliance with the Standards during their first 60 days of operation under the 6 month Conditional Licensure period. The provider was contacted by telephone to initiate the inspection. On the date of inspection, there were 13 children present with 3 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 3 child records and 2 staff records were reviewed.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. If you have any questions regarding this inspection, please contact the Licensing Inspector, Maria Robles at maria.robles@doe.virginia.gov.
Violations
11Standard 22.1-289.036-B-2
Based on record review, the center did not ensure to obtain fingerprint-based criminal history check determination letter prior to first day of employment.
Evidence:
1) The record for Staff #1 (start date 11/01/2021) had a fingerprint-based criminal history check determination
letter dated 11/05/2021.
2) The record for Staff #2 (start date 11/01/2021) had a fingerprint-based criminal history check determination letter dated 11/12/2021.
Evidence:
1) The record for Staff #1 (start date 11/01/2021) had a fingerprint-based criminal history check determination
letter dated 11/05/2021.
2) The record for Staff #2 (start date 11/01/2021) had a fingerprint-based criminal history check determination letter dated 11/12/2021.
Plan of Correction: Will have fingerprinting done prior to start date. This was another rule I was not aware of.
Standard 8VAC20-770-60-B
Based on record review, the center did not ensure that employees not be employed until the agency has the person's completed sworn statement or affirmation.
Evidence:
1) The sworn statement in the record for Staff #1 (start date 11/01/2021) was dated 11/02/2021.
2) The sworn statement in the record for Staff #2 (start date 11/01/2021) was dated 11/04/2021.
Evidence:
1) The sworn statement in the record for Staff #1 (start date 11/01/2021) was dated 11/02/2021.
2) The sworn statement in the record for Staff #2 (start date 11/01/2021) was dated 11/04/2021.
Plan of Correction: Will have the sworn statements signed by 1st day of employment. Was not aware of this deadline.
Standard 8VAC20-780-140-A
Based on record review, the provider did not did not ensure that all children 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 record for Child #1 (start date 10/11/2021) did not contain documentation of a physical examination.
Evidence:
1) The record for Child #1 (start date 10/11/2021) did not contain documentation of a physical examination.
Plan of Correction: Parent had lost the form and went to get a new one.
Standard 8VAC20-780-160-A
Based on record review, the center did not ensure that each staff member submit documentation of a negative tuberculosis (Tb) screening within 21 days of employment.
Evidence:
1) The records for Staff #1 (start date 11/01/2021) and Staff #2 (start date 11/01/2021), did not contain documentation of a Tb screening.
Evidence:
1) The records for Staff #1 (start date 11/01/2021) and Staff #2 (start date 11/01/2021), did not contain documentation of a Tb screening.
Plan of Correction: Staff will get that done.
Standard 8VAC20-780-240-B
Based on record review, the center did not ensure that staff complete orientation training prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
Evidence:
1) On the date of inspection, the records for Staff #1 (start date 11/01/2021) and Staff #2 (start date 11/01/2021) did not contain documentation of having completed the required orientation training.
Evidence:
1) On the date of inspection, the records for Staff #1 (start date 11/01/2021) and Staff #2 (start date 11/01/2021) did not contain documentation of having completed the required orientation training.
Plan of Correction: This has been completed for all current staff and will be done prior to start date for new staff. This was unknown to me.
Standard 8VAC20-780-245-L
Based on record review and interview with the director, the center did not ensure that there is always 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:
1) On the date of inspection, 0 out of 2 staff records reviewed, contained documentation of having completed the daily health observation of children training. 2) The director stated that there was no staff with the daily health observation of children training.
Evidence:
1) On the date of inspection, 0 out of 2 staff records reviewed, contained documentation of having completed the daily health observation of children training. 2) The director stated that there was no staff with the daily health observation of children training.
Plan of Correction: Once I find the course, I will complete it.
Standard 8VAC20-780-40-M
Based on review of documentation, the list of children's allergies was not kept confidential.
Evidence:
1) On the date of inspection, the list of children with allergies in Room #3 (primary) was posted on the wall of the class. This list did not have any cover over it nor was it concealed in any form, making all information easy to read, thus not being kept confidential.
Evidence:
1) On the date of inspection, the list of children with allergies in Room #3 (primary) was posted on the wall of the class. This list did not have any cover over it nor was it concealed in any form, making all information easy to read, thus not being kept confidential.
Plan of Correction: Let the staff know to cover it.
Standard 8VAC20-780-60-A
Based on record review, children's records did not contain all required information.
Evidence:
1) The record for Child #1 did not contain the address of a second person to call in an emergency if a parent cannot be reached.
2) The record for Child #3 did not contain the first date of attendance.
Evidence:
1) The record for Child #1 did not contain the address of a second person to call in an emergency if a parent cannot be reached.
2) The record for Child #3 did not contain the first date of attendance.
Plan of Correction: Will edit and have parent fill in missing info.
Standard 8VAC20-780-70
Based on record review, the center did not ensure that documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
Evidence:
1) The record for Staff #1 (start date 11/01/2021) did not contain documentation that two or more references were checked before employment.
2) The record for Staff #2 (start date 11/01/2021) did not contain documentation that a second reference was checked before employment.
Evidence:
1) The record for Staff #1 (start date 11/01/2021) did not contain documentation that two or more references were checked before employment.
2) The record for Staff #2 (start date 11/01/2021) did not contain documentation that a second reference was checked before employment.
Plan of Correction: Will ensure this is done. It was unclear to me if references were needed.
Standard 8VAC20-780-80-A
Based on review of documentation and interview with staff, the center did not maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs, for each group of children.
Evidence:
1) On the date of inspection there was no documentation of a written record of attendance for the children in the primary room , Room #3. The inspector requested Staff #4 to see the written record of attendance for this group and Staff #3 stated that it was not done. The inspector then requested to see the attendance that has been taken in the electronic application and Staff #3 stated it was not ready.
Evidence:
1) On the date of inspection there was no documentation of a written record of attendance for the children in the primary room , Room #3. The inspector requested Staff #4 to see the written record of attendance for this group and Staff #3 stated that it was not done. The inspector then requested to see the attendance that has been taken in the electronic application and Staff #3 stated it was not ready.
Plan of Correction: The attendance list was hanging on the wall in the classroom. Not sure why the staff said there wasn't one. Spoke to staff.
Standard 8VAC20-820-120-E-2
Based on required posted documents, the center did not ensure that the findings of the most recent inspection of the facility were posted as required.
Evidence:
1) On the date of inspection, the findings of the most recent inspection of the facility ((09/27/2021) were not posted.
Evidence:
1) On the date of inspection, the findings of the most recent inspection of the facility ((09/27/2021) were not posted.
Plan of Correction: Corrected during inspection.