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Inspection · 2021-10-27

Date

2021-10-27

Complaint Related

Licensing Inspector

Molly Muscat
(804) 588-2367

Areas Reviewed

22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
22VAC40-191 Background Checks (22VAC40-191)

Inspector Notes

An announced initial inspection was conducted on-site on October 27, 2021. The inspector was on-site from 10am-12:30pm. The owner, director, and an agent were present.

The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. The owner's record and the agent's record were reviewed.

New requirements became effective on October 13, 2021. The facility has not yet [fully] complied with the following requirement(s): emergency preparedness plan updates (standards 8VAC20-780-550-A and 8VAC20-780-550-B). The facility is to review the new requirements and work with their assigned inspector to ensure future compliance.

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.

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 today. Please 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 standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations

Standard 22VAC40-185-240-B

Based on a review of the center's policies and procedures, the center did not ensure that the required components were included in the staff handbook.
Evidence: The staff handbook did not address the following policies: 1. Procedures for supervising a child who may arrive after scheduled classes or activities including field trips have begun;
2. Procedures to confirm absence of a child when the child is scheduled to arrive from another program or from an agency responsible for transporting the child to the center;
3. Procedures for identifying where attending children are at all times, including procedures to ensure that all children are accounted for before leaving a field trip site and upon return to the center;
4. Procedures for action in case of lost or missing children, ill or injured children, medical emergencies, and general emergencies;
5. Policy for any administration of medication;
6. Emergency evacuation, relocation, shelter-in-place, and lockdown procedures; and
7. Precautions in transporting children, if applicable.

Plan of Correction: The required components have been added to the staff handbook and reviewed. The director will ensure staff sign off on procedures and are in compliance.

Standard 22VAC40-185-270-A

Based on observation on October 27, 2021, the center did not ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe, and operable condition.
Evidence: 1. The preschool area contained peeling paint approximately 1.5 x 2 inches in size.
2. The cubbies in the preschool area had multiple areas of the unit with chipped and peeling paint.

Plan of Correction: The area has been sanded down and has a border around it. The cubbies have been moved and replaced. The teachers and director have a daily checklist to ensure safety.

Standard 22VAC40-185-550-A

Based on interview on October 27, 2021 and review of records, the center did not ensure to have an emergency preparedness plan that addresses staff responsibility and facility readiness with respect to emergency evacuation and shelter-in-place. The plan, which shall be developed in consultation with local or state authorities, shall include the most likely to occur emergency scenario or scenarios, including fire, severe storms, loss of utilities, natural disaster, chemical spills, intruder, violence at or near the center, terrorism specific to the locality, and other situations, including facility damage that requires evacuation, lockdown, or shelter-in-place.
Evidence: 1. Administration stated the center's emergency plan was not developed in consultation with local or state authorities.
2. After review of the emergency preparedness plan it did not contain a plan to include intruder and terrorism.

Plan of Correction: The emergency preparedness plan was reviewed by authorities on October 29, 2021. The intruder and terrorism plan was included. An annual review of the emergency plan will be performed by the director to ensure proper compliance.

Standard 22VAC40-185-550-B

Based on a review of records, the center did not ensure the emergency preparedness plan contains all the procedural components.
Evidence: 1. The procedural components did not contain documentation for sounding of alarms, such as intruder, shelter-in-place, or chemical hazard.
2. The emergency communication did not contain the a.) establishment of center emergency officer and back-up officer to include 24-hour contact telephone number for each; b.) notification of local authorities, such as fire and rescue, law enforcement, emergency medical services, poison control, health department, and parents and local media; and
c. Availability and primary use of communication tools.
3. Evacuation plan did not include a.) Assembly points, head counts, primary and secondary means of egress, and complete evacuation of the buildings; b.) Securing of essential documents and special healthcare supplies to be carried to the designated assembly points c.) Method of communication after the evacuation;
4. The shelter-in-place did not contain a.) scenario applicability, for a tornado, inside assembly points, head counts, and primary and secondary means of access and egress; b.) Securing of essential documents, and special health supplies to be carried to the designated assembly points; c.) Method of communication after the shelter-in-place

Plan of Correction: All components have been added and reviewed. The plan will be reviewed annually by the director to ensure compliance.

Standard 22VAC40-191-40-C-1-A

Based on a review of owner record and interview on October 27, 2021, the center did not ensure to obtain the results of a central registry check and sworn statement of affirmation upon application for licensure or registration as a child welfare agency.
Evidence: 1. The record of the Owner did not contain documentation of a sworn statement. The sworn statement was completed during the inspection.
2. The owner acknowledged the sworn statement was not complete when it was asked for.

Plan of Correction: The sworn statement was completed during the inspection. Files will be updated annually to ensure proper timing for background checks.

Standard 22VAC40-191-40-C-1-B

Based on a review of agent record and interview on October 27, 2021, the center did not ensure to obtain the results of a central registry check and sworn statement of affirmation upon application for licensure or registration as a child welfare agency.
Evidence: 1. The record of Agent #1 did not contain documentation of central registry results and a sworn statement. The sworn statement was completed during the inspection.
2. Administration acknowledged the results of the central registry were not in the record.

Plan of Correction: The sworn statement was completed during the inspection. The central registry app had been submitted but was not back by the time of inspection. Files will be updated annually to ensure proper timing for background checks.

View original record on Virginia Department of Social Services