Inspection · 2024-03-04
Date
2024-03-04
Complaint Related
No
Licensing Inspector
Tara K Martin
(804) 588-2371
(804) 588-2371
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
8VAC20-770 Background Checks
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted on 03/04/2024 and concluded with an electronic record review on 03/05/2024. There were 21 children, ages 21 months - 4 years, 4 staff members providing direct care and supervision, and various support staff present during the inspection. The inspectors reviewed compliance in the areas of administration, staff qualifications and trainings, physical plant, staffing and supervision, programs, emergencies, and nutrition. The children were observed during naptime. A total of 5 children?s records, and 6 staff records were reviewed. The inspectors discussed the following with the provider: diaper disposal. Two inspectors arrived for the inspection at approximately 12:20 pm and departed at approximately 2:30 pm. The inspection was concluded on 03/21/2024.
A self-report inspection was also conducted on this date. Violations related to the self-report are included on the self-report inspection.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider.
Violations
9Standard 8VAC20-770-60-B
Based on record review and interviews with staff, the center failed to ensure that an employee must not be employed until the agency has the person?s completed sworn statement or affirmation.
Evidence: Staff 5 had a hire date of 07/25/2023. No sworn statement was available for review. Staff 2 confirmed that no sworn statement was available for review.
Evidence: Staff 5 had a hire date of 07/25/2023. No sworn statement was available for review. Staff 2 confirmed that no sworn statement was available for review.
Plan of Correction: Staff has a completed sworn statement in file now.
Standard 8VAC20-780-160-C
SYSTEMIC VIOLATION
Based on record review and interviews with staff, the center failed to ensure that at least every two years from the date of the initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening.
Evidence: The most recent tuberculosis screening for Staff 4 was dated 10/20/2021: there was not a follow-up test/screening for 2023 available for review. Staff 2 confirmed there was no 2023 test/ screening available for review.
Based on record review and interviews with staff, the center failed to ensure that at least every two years from the date of the initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening.
Evidence: The most recent tuberculosis screening for Staff 4 was dated 10/20/2021: there was not a follow-up test/screening for 2023 available for review. Staff 2 confirmed there was no 2023 test/ screening available for review.
Plan of Correction: Staff 4 completed a new TB screening on 3/11/2024 and was read on 3/13/2024.
Standard 8VAC20-780-240-A
Based on record review and interviews with staff, the center failed to ensure that all staff complete the Virginia Department of Education-sponsored orientation within 90 calendar days of hire.
Evidence:
1. Staff 1 had a hire date of 06/03/2023; no documentation of Virginia Department of Education-sponsored orientation was available for review.
2. Staff 5 had hire date of 07/25/2023; no documentation of Virginia Department of Education-sponsored orientation was available for review.
Evidence:
1. Staff 1 had a hire date of 06/03/2023; no documentation of Virginia Department of Education-sponsored orientation was available for review.
2. Staff 5 had hire date of 07/25/2023; no documentation of Virginia Department of Education-sponsored orientation was available for review.
Plan of Correction: All staff have completed. On 3/13/2024 a staff training and orientation was conducted for all staff and files were updated.
Standard 8VAC20-780-240-B
Based on record review and staff interviews, the center failed to ensure that staff shall 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. Staff 1 had a hire date of 06/03/2023. There was no documentation to verify that Staff 1 had completed orientation training in the required timeframe. Staff 2 verified no documentation was available. Staff 1 was observed working on 03/04/2024.
2. Staff 3 had a hire date of 11/16/2023. There was no documentation to verify that Staff 3 had completed orientation training in the required timeframe. Staff 2 verified no documentation was available. Staff 3 was observed working on 03/04/2024.
3. Staff 5 had a hire date of 07/25/2023. There was no documentation to verify that Staff 5 had completed orientation training in the required timeframe. Staff 2 verified no documentation was available. Staff 5 was observed working on 03/04/2024.
Evidence:
1. Staff 1 had a hire date of 06/03/2023. There was no documentation to verify that Staff 1 had completed orientation training in the required timeframe. Staff 2 verified no documentation was available. Staff 1 was observed working on 03/04/2024.
2. Staff 3 had a hire date of 11/16/2023. There was no documentation to verify that Staff 3 had completed orientation training in the required timeframe. Staff 2 verified no documentation was available. Staff 3 was observed working on 03/04/2024.
3. Staff 5 had a hire date of 07/25/2023. There was no documentation to verify that Staff 5 had completed orientation training in the required timeframe. Staff 2 verified no documentation was available. Staff 5 was observed working on 03/04/2024.
Plan of Correction: On 3/13/2024 a staff training and orientation was conducted for all staff and documentation was added to the files.
Standard 8VAC20-780-270-A
Based on observation, the center failed to ensure that areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition.
Evidence:
1. At the bottom of the steps to the front porch was a wooden board covering a muddy spot. This board contained 2 nails sticking out of the side of the board and 1 nail head sticking up out of the top of the board and is a puncture hazard. These steps are at the entrance used by children to enter the facility and children had to step on the board to access the steps to enter the building.
2. One rail baluster on the front porch was loose and exposing a nail. This is the entrance children use to enter the facility.
3. The cabinet under the sink in the first-floor restroom was broken: knobs were missing exposing wooden dowels. Children were observed using this restroom.
Evidence:
1. At the bottom of the steps to the front porch was a wooden board covering a muddy spot. This board contained 2 nails sticking out of the side of the board and 1 nail head sticking up out of the top of the board and is a puncture hazard. These steps are at the entrance used by children to enter the facility and children had to step on the board to access the steps to enter the building.
2. One rail baluster on the front porch was loose and exposing a nail. This is the entrance children use to enter the facility.
3. The cabinet under the sink in the first-floor restroom was broken: knobs were missing exposing wooden dowels. Children were observed using this restroom.
Plan of Correction: We have removed the wood and broken plank from the porch. 1. the wooden board was placed by early morning staff due to rain. the board was removed before inspection ended and pebbles were put down. 2. Rail baluster was removed. 3. The sink vanity has been replaced.
Standard 8VAC20-780-280-B
REPEAT VIOLATION
Based on observations, the center failed to ensure that hazardous substances such as cleaning materials, insecticides and pesticides shall be kept in a locked place using a safe locking method that prevents access by children.
Evidence:
The cabinet under the sink in first floor restroom was unlocked. Half gallons of bleach, bleach spray bottles, disinfecting spray and glass cleaner were in the unlocked cabinet. Children were observed using this restroom.
Based on observations, the center failed to ensure that hazardous substances such as cleaning materials, insecticides and pesticides shall be kept in a locked place using a safe locking method that prevents access by children.
Evidence:
The cabinet under the sink in first floor restroom was unlocked. Half gallons of bleach, bleach spray bottles, disinfecting spray and glass cleaner were in the unlocked cabinet. Children were observed using this restroom.
Plan of Correction: We replaced the entire vanity and are using a lock that remains locked unless a starr member is removing supplies.
Standard 8VAC20-780-440-E
Based on observations, the center failed to ensure that there shall be at least 12 inches of space between occupied cots, beds or rest mats.
Evidence:
1. In the large room on the first floor, there were 8 occupied rest mats that were spaced less than 12 inches apart: the space between mats varied from approximately less than 1 inch to approximately 3 inches.
2. In the small room on the first floor, there were 7 occupied rest mats that were spaced less than 12 inches apart: the space between mats varied from approximately less than 1 inch to approximately 6 inches.
Evidence:
1. In the large room on the first floor, there were 8 occupied rest mats that were spaced less than 12 inches apart: the space between mats varied from approximately less than 1 inch to approximately 3 inches.
2. In the small room on the first floor, there were 7 occupied rest mats that were spaced less than 12 inches apart: the space between mats varied from approximately less than 1 inch to approximately 6 inches.
Plan of Correction: Since inspection we used a ruler to ensure mates are spaced at least 12 inches apart.
Standard 8VAC20-780-70
SYSTEMIC VIOLATION
SECOND REPEAT VIOLATION
Based on record review and interviews with staff, the center failed to ensure that staff records contain all of the elements as required by the standards.
Evidence:
1. The record for Staff 1, date of hire of 06/03/2023, did not contain the following: name, address, and telephone number of person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities. Staff 2 confirmed this information was not available.
2. The record for Staff 2, date of hire of 06/08/2022, did not contain the following: name, address, and telephone number of person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities. Staff 2 confirmed this information was not available.
3. The record for Staff 3, date of hire of 11/16/2023, did not contain the following: job title, date of employment, name, address, and telephone number of person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities. Staff 2 confirmed this information was not available.
4. The record for Staff 4, date of hire unknown, did not contain the following: name, address, and telephone number of person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities. Staff 2 confirmed this information was not available.
5. The record for Staff 5, date of hire of 07/25/2023, did not contain the following: name, address, and telephone number of person to be notified in an emergency, information about any health problems that may interfere with fulfilling the job responsibilities, and documentation to demonstrate that the individual possesses the education, certification and experience required by the job position. The record for Staff 5 indicated a position of program lead. Staff 2 confirmed this information was not available.
SECOND REPEAT VIOLATION
Based on record review and interviews with staff, the center failed to ensure that staff records contain all of the elements as required by the standards.
Evidence:
1. The record for Staff 1, date of hire of 06/03/2023, did not contain the following: name, address, and telephone number of person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities. Staff 2 confirmed this information was not available.
2. The record for Staff 2, date of hire of 06/08/2022, did not contain the following: name, address, and telephone number of person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities. Staff 2 confirmed this information was not available.
3. The record for Staff 3, date of hire of 11/16/2023, did not contain the following: job title, date of employment, name, address, and telephone number of person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities. Staff 2 confirmed this information was not available.
4. The record for Staff 4, date of hire unknown, did not contain the following: name, address, and telephone number of person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities. Staff 2 confirmed this information was not available.
5. The record for Staff 5, date of hire of 07/25/2023, did not contain the following: name, address, and telephone number of person to be notified in an emergency, information about any health problems that may interfere with fulfilling the job responsibilities, and documentation to demonstrate that the individual possesses the education, certification and experience required by the job position. The record for Staff 5 indicated a position of program lead. Staff 2 confirmed this information was not available.
Plan of Correction: 1. File was updated with all requested information. 2. File was updated with all requested information.3. File was updated with all requested information. 4. File was updated with all requested information. This includes a hire date. File was updated with requested information. This staff member completed the program at DCC and this documentation is and has been in the file since Dec. 2023. We were informed during inspection that only a sworn statemen was missing.
Standard 8VAC20-780-80-A
SYSTEMIC VIOLATION
REPEAT VIOLATION
Based on observation, the center failed to ensure that for each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
Evidence:
1. There were 12 children in care in the large room on the first floor. The attendance record for that group indicated 2 children present.
2. There were 9 children in care in the small room on the first floor. The attendance record for that group indicated 7 children present.
REPEAT VIOLATION
Based on observation, the center failed to ensure that for each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
Evidence:
1. There were 12 children in care in the large room on the first floor. The attendance record for that group indicated 2 children present.
2. There were 9 children in care in the small room on the first floor. The attendance record for that group indicated 7 children present.
Plan of Correction: We have created an attendance long for children that are in each room at nap, during learning, outside play and overall center attendance. These are updated upon arrival and departure throughout the day.