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 03/06/2024 in response to a self-reported incident received on 03/01/2024 related to transportation. The inspectors reviewed 1 children?s record, 1 staff record, center documents and policies and procedures, and interviewed staff members. On 03/04/2024, two inspectors arrived at approximately 12:20 pm and departed at approximately 2:30 pm and on 03/06/2024, two inspectors arrived at approximately 3:35 pm and departed at approximately 4:30 pm. Concerns for capacity and ratio were discovered during the investigation. The inspection was concluded on 03/25/2024.
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. A mandated inspection was also conducted on 03/04/2024.
Violations
16Standard 22.1-289.035-B-4
Based on record review and interviews with staff, the center failed to obtain a copy of a child abuse and neglect search from any state in which the individual has resided in the preceding five years.
Evidence: Staff 6 had a hire date of 01/15/2024. The record contained documentation that Staff 6 has resided outside of the state of Virginia within the preceding five years. There was not an out of state child abuse and neglect registry check from all of the states in which the individual has resided in the preceding five years available for review during the inspection. Staff 2 confirmed the out of state child abuse and neglect registry has not been requested.
Evidence: Staff 6 had a hire date of 01/15/2024. The record contained documentation that Staff 6 has resided outside of the state of Virginia within the preceding five years. There was not an out of state child abuse and neglect registry check from all of the states in which the individual has resided in the preceding five years available for review during the inspection. Staff 2 confirmed the out of state child abuse and neglect registry has not been requested.
Plan of Correction: The staff record has been updated with required info.
Standard 8VAC20-780-130-A
SYSTEMIC VIOLATION
REPEAT VIOLATION
Based on record review and interviews with staff, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence: Staff 3 confirmed the first date of attendance for Child 1 was 08/25/2022. Staff 2 and Staff 3 confirmed that no documentation of immunizations for Child 1 was available for review during the inspection.
REPEAT VIOLATION
Based on record review and interviews with staff, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence: Staff 3 confirmed the first date of attendance for Child 1 was 08/25/2022. Staff 2 and Staff 3 confirmed that no documentation of immunizations for Child 1 was available for review during the inspection.
Plan of Correction: We have been reviewing files to ensure shot records are included.
Standard 8VAC20-780-140-A
SYSTEMIC VIOLATION
SECOND REPEAT VIOLATION
Based on record review and interviews with staff, the center failed to obtain documentation that each child shall have a physical examination by or under the direction of a physician before the child?s attendance or within 30 days after the first day of attendance.
Evidence: Staff 3 confirmed the first date of attendance for Child 1 was 08/25/2022. Staff 2 and Staff 3 confirmed that documentation of a physical examination for Child 1 was not available for review during the inspection.
SECOND REPEAT VIOLATION
Based on record review and interviews with staff, the center failed to obtain documentation that each child shall have a physical examination by or under the direction of a physician before the child?s attendance or within 30 days after the first day of attendance.
Evidence: Staff 3 confirmed the first date of attendance for Child 1 was 08/25/2022. Staff 2 and Staff 3 confirmed that documentation of a physical examination for Child 1 was not available for review during the inspection.
Plan of Correction: We are ensuring files contain required info including physicals.
Standard 8VAC20-780-160-A
SYSTEMIC VIOLATION
Based on record review, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence: Staff 6 had a hire date of 01/15/2024. The date on the tuberculosis screening in the record was 01/23/2024.
Based on record review, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence: Staff 6 had a hire date of 01/15/2024. The date on the tuberculosis screening in the record was 01/23/2024.
Plan of Correction: We will not hire anyone until their TB screening is complete.
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: Staff 1 had a hire date of 1/15/2024. 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. Staff 1 confirmed they had not been provided with orientation training.
Evidence: Staff 1 had a hire date of 1/15/2024. 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. Staff 1 confirmed they had not been provided with orientation training.
Plan of Correction: All staff files have been updated with orientation and training info.
Standard 8VAC20-780-340-A
Based on observation and document review, the center failed to ensure that when staff are supervising children, they shall always ensure their care, protection and guidance.
Evidence:
1. On 03/01/2024, Child 1 (age 7 years) was not properly secured in a child restraint device and was transported on the center?s red transit van from approximately 3:05 pm to approximately 4:50 pm. The driver, Staff 1, confirmed they were unfamiliar with the location of the schools and the routes to the schools and did not have a document on the center van containing information on each route or local emergency contacts. Staff 1 had not been provided orientation training prior to being assigned to drive alone to transport children. Staff 1 stated they did not have cellular service on 03/01/2024 and was unable to communicate with the center or use a navigational application which resulted in the driver being lost, entering another state, and unable to find the way back to center for approximately 105 minutes. Child 1 did not have a record at the center and Staff 1 only had the first name of the child. Due to lack of communication with Staff 1 and not knowing their whereabouts, Staff 3 contacted local police to report a possible lost/missing child.
2. On 03/06/2024 at approximately 3:35 pm, there was a total of 66 persons in the facility; 57 children, ages 21 months- 7 years, and 9 adults. The center has a licensing capacity of 32 children. The maximum occupancy, as declared by the is certificate of occupancy, is 37 persons.
.
Evidence:
1. On 03/01/2024, Child 1 (age 7 years) was not properly secured in a child restraint device and was transported on the center?s red transit van from approximately 3:05 pm to approximately 4:50 pm. The driver, Staff 1, confirmed they were unfamiliar with the location of the schools and the routes to the schools and did not have a document on the center van containing information on each route or local emergency contacts. Staff 1 had not been provided orientation training prior to being assigned to drive alone to transport children. Staff 1 stated they did not have cellular service on 03/01/2024 and was unable to communicate with the center or use a navigational application which resulted in the driver being lost, entering another state, and unable to find the way back to center for approximately 105 minutes. Child 1 did not have a record at the center and Staff 1 only had the first name of the child. Due to lack of communication with Staff 1 and not knowing their whereabouts, Staff 3 contacted local police to report a possible lost/missing child.
2. On 03/06/2024 at approximately 3:35 pm, there was a total of 66 persons in the facility; 57 children, ages 21 months- 7 years, and 9 adults. The center has a licensing capacity of 32 children. The maximum occupancy, as declared by the is certificate of occupancy, is 37 persons.
.
Plan of Correction: We have reduced the amount of children we are providing childcare to at the same time to remain within our Certificate of occupancy. Started reducing on 3/7 and have continued to do so to be in compliance.
Standard 8VAC20-780-350-B-4
Based on observation and record review, the center failed to ensure that the required staff to child ratio shall be maintained for 3-year-olds up to school age eligible.
Evidence: On 03/06/2024 at approximately 3:35 pm, there were 16 children observed in the room to the left at the top of the stairs with 1 staff member. The youngest child was 3 years old. The required staff ratio for this group of children was 1:10. Two staff would be required.
Evidence: On 03/06/2024 at approximately 3:35 pm, there were 16 children observed in the room to the left at the top of the stairs with 1 staff member. The youngest child was 3 years old. The required staff ratio for this group of children was 1:10. Two staff would be required.
Plan of Correction: 3/7/24 We began reducing our amount of children. We have reduced the amount of children and are complying with ratio.
Standard 8VAC20-780-40-E
SYSTEMIC VIOLATION
Based on observation, review of required policies and procedures, and interviews with staff, the center failed to maintain the operational responsibility of the licensee to ensure that the center?s activities, services and facilities are maintained in compliance with the center?s own policies and procedures that are required by the standards and the terms of the current license issued by the department.
Evidence:
1. The center?s transportation policy states each child will be placed in a proper car seat and properly restrained with a safety belt. Staff 1 confirmed that on 03/01/2023, Child 1 (age 7 years) was not placed in the proper car seat during transit in the red transit van from school to the center.
2. The center?s transportation policy states the attendance sheet will always be checked when arriving and departing a destination. Staff 2 and Staff 3 confirmed that on 03/01/2023, no attendance sheet was used while children were picked up and transported from schools to the center.
3. The term of current license issued by the department shows a capacity of 32 children. The stipulation that is shown on the face of the license that the maximum occupancy of the building is 37, including staff. On 03/06/2024 at approximately 3:35 pm, there were a total of 57 children, 8 staff, and 1 outside provider present, for a total of 66 building occupants.
Based on observation, review of required policies and procedures, and interviews with staff, the center failed to maintain the operational responsibility of the licensee to ensure that the center?s activities, services and facilities are maintained in compliance with the center?s own policies and procedures that are required by the standards and the terms of the current license issued by the department.
Evidence:
1. The center?s transportation policy states each child will be placed in a proper car seat and properly restrained with a safety belt. Staff 1 confirmed that on 03/01/2023, Child 1 (age 7 years) was not placed in the proper car seat during transit in the red transit van from school to the center.
2. The center?s transportation policy states the attendance sheet will always be checked when arriving and departing a destination. Staff 2 and Staff 3 confirmed that on 03/01/2023, no attendance sheet was used while children were picked up and transported from schools to the center.
3. The term of current license issued by the department shows a capacity of 32 children. The stipulation that is shown on the face of the license that the maximum occupancy of the building is 37, including staff. On 03/06/2024 at approximately 3:35 pm, there were a total of 57 children, 8 staff, and 1 outside provider present, for a total of 66 building occupants.
Plan of Correction: All vehicles are equipped with the proper restraints and car seats. Attendance sheets are in vehicles during transportation. We have reduced the amount of children we provide care to at the same time to stay within the amount our occupancy allows.
Standard 8VAC20-780-540-A
SYSTEMIC VIOLATION
Based on observation and interviews with staff, the center failed to ensure that a first aid kit shall be wherever children are in care.
Evidence: There was no first aid kit on the center?s red transit van. Staff 1 and Staff 3 confirmed that the van was used to transport Child 1 from school on 03/01/2024.
Based on observation and interviews with staff, the center failed to ensure that a first aid kit shall be wherever children are in care.
Evidence: There was no first aid kit on the center?s red transit van. Staff 1 and Staff 3 confirmed that the van was used to transport Child 1 from school on 03/01/2024.
Plan of Correction: All vehicles have a first aid kit.
Standard 8VAC20-780-540-C
SYSTEMIC VIOLATION
Based on observation, the center failed to ensure that the required first aid kits shall include all required items.
Evidence:
1. The first aid kit in the center?s gold transit van was missing the following required items: scissors, tweezers, adhesive tape, thermometer, triangular bandages, gloves and first aid instruction manual.
2. The first aid kit in the center?s tan transit van was missing the following required items: scissors, tweezers, gauze, adhesive tape, thermometer, triangular bandages, gloves and first aid instruction manual.
Based on observation, the center failed to ensure that the required first aid kits shall include all required items.
Evidence:
1. The first aid kit in the center?s gold transit van was missing the following required items: scissors, tweezers, adhesive tape, thermometer, triangular bandages, gloves and first aid instruction manual.
2. The first aid kit in the center?s tan transit van was missing the following required items: scissors, tweezers, gauze, adhesive tape, thermometer, triangular bandages, gloves and first aid instruction manual.
Plan of Correction: Six new first aid kits were purchased as well as additional supplies to ensure there are enough.
Standard 8VAC20-780-550-K
SYSTEMIC VIOLATION
Based on interviews with staff, the center failed to prepare a document containing local emergency contact information, potential shelters, hospitals, evacuation routes, etc., that pertain to each site frequently visited or of routes frequently driven by center staff for center business such as field trips or pick up or drop off of children to or from schools etc. This document must be kept in vehicles that centers use to transport children to and from the center.
Evidence: Staff 3 confirmed there was no document. Staff 1 confirmed they did not have access to any document that contained all the required components of the standards, which would include information pertaining to each route frequently driven. The driver, Staff 1, reported getting lost while driving the route to a school on 03/01/2024.
Based on interviews with staff, the center failed to prepare a document containing local emergency contact information, potential shelters, hospitals, evacuation routes, etc., that pertain to each site frequently visited or of routes frequently driven by center staff for center business such as field trips or pick up or drop off of children to or from schools etc. This document must be kept in vehicles that centers use to transport children to and from the center.
Evidence: Staff 3 confirmed there was no document. Staff 1 confirmed they did not have access to any document that contained all the required components of the standards, which would include information pertaining to each route frequently driven. The driver, Staff 1, reported getting lost while driving the route to a school on 03/01/2024.
Plan of Correction: All vehicles are now equipped with the required info.
Standard 8VAC20-780-580-C
Based on staff interviews, the center failed to ensure that during transportation of children the Virginia state statutes about safety belts and child restraints are followed as required by the Code of Virginia and that the information required by the standard is in the transportation vehicle.
Evidence:
1. The Code of Virginia requires that any child, up to age eight, shall be properly secured in a child restraint device of a type which meets the standards adopted by the United States Department of Transportation. Staff 1 confirmed that on 03/01/2024, Child 1 (age 7 years) was not secured in a child restraint device. Child 1 was transported on the center?s red transit van from approximately 3:05 pm to approximately 4:50 pm without being properly restrained.
2. Staff 1 and Staff 3 both verified that the vehicle used for transportation did not contain the following required information: a 911 or local dial number for police, fire and emergency medical services and the number of the regional poison control center; the center?s name, address and phone number; a list of the names of the children being transported.
Evidence:
1. The Code of Virginia requires that any child, up to age eight, shall be properly secured in a child restraint device of a type which meets the standards adopted by the United States Department of Transportation. Staff 1 confirmed that on 03/01/2024, Child 1 (age 7 years) was not secured in a child restraint device. Child 1 was transported on the center?s red transit van from approximately 3:05 pm to approximately 4:50 pm without being properly restrained.
2. Staff 1 and Staff 3 both verified that the vehicle used for transportation did not contain the following required information: a 911 or local dial number for police, fire and emergency medical services and the number of the regional poison control center; the center?s name, address and phone number; a list of the names of the children being transported.
Plan of Correction: All children up to age 8 will be transported in proper restraint device. We have purchased over 20 seats for vehicles. All vehicles have a transportation log. The log include the children being transported names and times. Three additional cell phones have been purchased for drivers to use and all required info is in vehicles.
Standard 8VAC20-780-580-L
Based on interviews with staff, the center failed to obtain parental permission for transportation and field trips before the scheduled activity.
Evidence: Staff 2 and Staff 3 confirmed there was no parental permission to transport for Child 1 available for review during the inspection. Staff 1 confirmed that Child 1 was transported from school to the center on 03/01/2024.
Evidence: Staff 2 and Staff 3 confirmed there was no parental permission to transport for Child 1 available for review during the inspection. Staff 1 confirmed that Child 1 was transported from school to the center on 03/01/2024.
Plan of Correction: The files contain transportation permission slips.
Standard 8VAC20-780-60-A
SYSTEMIC VIOLATION
REPEAT VIOLATION
Based on record review and interviews with staff, the center failed to ensure that the separate record for each enrolled child contains all of the elements as required by the standards.
Evidence: Staff 3 confirmed the first date of attendance for Child 1 was 08/25/2022. Staff 2 and Staff 3 confirmed that no record for Child 1 was available for review during the inspection.
REPEAT VIOLATION
Based on record review and interviews with staff, the center failed to ensure that the separate record for each enrolled child contains all of the elements as required by the standards.
Evidence: Staff 3 confirmed the first date of attendance for Child 1 was 08/25/2022. Staff 2 and Staff 3 confirmed that no record for Child 1 was available for review during the inspection.
Plan of Correction: Record was overlooked and since inspection, all requested info has been given to inspector. Since then all records are continuously being reviewed.
Standard 8VAC20-780-70
THIRD REPEAT VIOLATION
SYSTEMIC 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: The record for Staff 6 did not contain the following: job title, 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. Staff 2 confirmed this information was not available.
SYSTEMIC 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: The record for Staff 6 did not contain the following: job title, 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. Staff 2 confirmed this information was not available.
Plan of Correction: All staff files now contain an emergency contact paper as well as health issues.
Standard 8VAC20-780-80-A
SYSTEMIC VIOLATION
SECOND 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: On 3/06/2024 at approximately 3:35 pm, there were 14 children in care in the large room on the first floor. Staff 2 confirmed there was no attendance record for this group of children.
SECOND 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: On 3/06/2024 at approximately 3:35 pm, there were 14 children in care in the large room on the first floor. Staff 2 confirmed there was no attendance record for this group of children.
Plan of Correction: All parents are required to sign children in and out of the log books in which the arrival and departure times are documented. Each room and outside play area have an attendance sheet.