Inspection · 2022-05-19
Date
2022-05-19
Complaint Related
No
Licensing Inspector
Monique Anderson
(540) 309-2397
(540) 309-2397
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
? 63.2 Child Abuse & Neglect
? 8VAC20-790 Subsidy Regulations.
Inspector Notes
The licensing inspector conducted an unannounced renewal inspection, at which play groups, lunch time, and rest time were observed. Children were observed; and staff and children files and other documentation were reviewed. 22 children were found to be in care. Also, the license expires in less than 1 month and it is critical for you to demonstrate improved performance as soon as possible. There were numerous areas of non-complaince, these areas need to be in compliance in order to obtain a renewed license. Please contact me if you need further assistance. Thank you for your cooperation.
Violations
17Standard 8VAC20-770-40-D-1-b
Based on review of staff files and discussions with administration the facility failed to maintain compliance with this standard as required relating to employee background checks.
Evidence:
Staff file #4 did not have a completed Central Registry Clearance on file. Administration stated it had been mailed off, not within 7 days of employment, was returned for an error and as of the inspection had not been resubmitted as required. The allowed 30 days to obtain this had since expired. The staff member had been actively working with the children for more than 30 days.
Evidence:
Staff file #4 did not have a completed Central Registry Clearance on file. Administration stated it had been mailed off, not within 7 days of employment, was returned for an error and as of the inspection had not been resubmitted as required. The allowed 30 days to obtain this had since expired. The staff member had been actively working with the children for more than 30 days.
Plan of Correction: Staff has been notified of noncompliance and is placed on hold until background returns, background was mailed via overnight 5/19. Called central registry 5/24 and they stated 7-10 days once received since it was a previous submission Plan to contact employee once central has been issued.
Standard 8VAC20-780-130-A
Based on review of children records the facility failed to maintain compliance with this standard as required related to immunization verification.
Evidence:
Child record #2 did not have immunization documentation on file as required, the child has been in attendance.
Evidence:
Child record #2 did not have immunization documentation on file as required, the child has been in attendance.
Plan of Correction: All children?s records pulled and completed to its entirety by parents at time of pick-up on 5/19-5/23 ; Parents were provided child?s file and completed on site, missing documents that could not be provided at this time were issued a week notice stating effective June 1st if documents are not provided children are unable to return due to standard licensing requirements.
Going forward: Childrens Lounge enrollment process has been updated, parents must provide all documentation and enrollment forms before the child is accepted, new students we will no longer have 30 days to provide a complete file. Owner/director will then update file with necessary information before filing enrollment.
Going forward: Childrens Lounge enrollment process has been updated, parents must provide all documentation and enrollment forms before the child is accepted, new students we will no longer have 30 days to provide a complete file. Owner/director will then update file with necessary information before filing enrollment.
Standard 8VAC20-780-140-A
Based on review of children records the facility failed to maintain compliance with this standard as required related to a physical.
Evidence:
Child records #1 and #2 did not have proof of physical as required. Both children have been in attendance.
Evidence:
Child records #1 and #2 did not have proof of physical as required. Both children have been in attendance.
Plan of Correction: All children?s records pulled and completed to its entirety by parents at time of pick-up on 5/19-5/23 ; Parents were provided child?s file and completed on site, missing documents that could not be provided at this time were issued a week notice stating effective June 1st if documents are not provided children are unable to return due to standard licensing requirements.
Going forward: Childrens Lounge enrollment process has been updated, parents must provide all documentation and enrollment forms before the child is accepted, new students we will no longer have 30 days to provide a complete file. Owner/director will then update file with necessary information before filing enrollment.
Going forward: Childrens Lounge enrollment process has been updated, parents must provide all documentation and enrollment forms before the child is accepted, new students we will no longer have 30 days to provide a complete file. Owner/director will then update file with necessary information before filing enrollment.
Standard 8VAC20-780-240-C
Based on review of staff records the facility failed to maintain compliance with this standard as required relating to proof of orientation.
Evidence:
Staff records #1 did not have proof of orientation as required. The staff was actively working with the children, within the facility.
Evidence:
Staff records #1 did not have proof of orientation as required. The staff was actively working with the children, within the facility.
Plan of Correction: Staff orientation binder is located at the front desk and labeled ?staff orientation?. Staff are required to complete orientation within the 1st weeks of hire.
We provided observation training, hands on and online training during M-F (if required one Saturday of the month will be reserved for staff training )
Going forward owner/director will ensure orientation is completed before staff is allowed in classroom and working with children.
We provided observation training, hands on and online training during M-F (if required one Saturday of the month will be reserved for staff training )
Going forward owner/director will ensure orientation is completed before staff is allowed in classroom and working with children.
Standard 8VAC20-780-280-B
Based on inspection of the facility the required compliance with this standard was not met regarding locking of hazardous materials.
Evidence:
Under the diaper station, in the toddler-2year old area, there were cleaning agents that were not locked as required. Children within the area also had access.
Evidence:
Under the diaper station, in the toddler-2year old area, there were cleaning agents that were not locked as required. Children within the area also had access.
Plan of Correction: Locked cabinets are provided for staff to house cleaning agents next to changing table.
A sign has been posted at teacher?s eye level as a reminder to staff to lock cleaning agents properly and a verbal reminder to staff has been issued 5/24/22.
Going forward in-services will be provided weekly to ensure our staff keep knowledge of properly handling chemical agents in a childcare setting
A sign has been posted at teacher?s eye level as a reminder to staff to lock cleaning agents properly and a verbal reminder to staff has been issued 5/24/22.
Going forward in-services will be provided weekly to ensure our staff keep knowledge of properly handling chemical agents in a childcare setting
Standard 8VAC20-780-350-B-2
Based on inspection of the facility the required compliance with this standard was not met regarding ratios.
Evidence:
In the toddler-2 year old class there were 8 children with 1 staff at the beginning of this inspection, which began at 10:40am. Attendance records showed that at approximately 9am, with the arrival of the 6th child into the group, the group became out of ratio. Ratio remained out of compliance until another staff member arrived at approximately 11am. At approximately 11:10am this staff member went into the adjacent kitchen area, with the door closed, to finish prepping lunch for the center. Therefore, ratio was then out of compliance since the staff member was not actively able to supervise the children. This process continued until lunch was served at approximately 11:30am. Children in this class were aged 18mths-2yrs. The required ratio for this class was 1 staff to 5 children.
Evidence:
In the toddler-2 year old class there were 8 children with 1 staff at the beginning of this inspection, which began at 10:40am. Attendance records showed that at approximately 9am, with the arrival of the 6th child into the group, the group became out of ratio. Ratio remained out of compliance until another staff member arrived at approximately 11am. At approximately 11:10am this staff member went into the adjacent kitchen area, with the door closed, to finish prepping lunch for the center. Therefore, ratio was then out of compliance since the staff member was not actively able to supervise the children. This process continued until lunch was served at approximately 11:30am. Children in this class were aged 18mths-2yrs. The required ratio for this class was 1 staff to 5 children.
Plan of Correction: Staff ratio will be met by ensuring staff come at their set scheduled time. If and when staff do not came in by their appointed schedule lead on staff must contact backup to come in immediately if staff are unable to come in parents will be called to pick up children due to staff ratio.
Going forward: A staff member will be on a split shift 8-12:30 and returning 2-6 to cover the teacher aide position to ensure 2 staff members are present for the entire day in both preschool and toddler room to meet ratio needs.
Going forward: A staff member will be on a split shift 8-12:30 and returning 2-6 to cover the teacher aide position to ensure 2 staff members are present for the entire day in both preschool and toddler room to meet ratio needs.
Standard 8VAC20-780-360-A
Based on inspection of the facility the required compliance with this standard was not met regarding variety of daily activities.
Evidence:
The children in the preschool area and the toddler/2year old area were not engaged in a variety of activities as required. During the inspection, both classes had self-directed free play only. Children were not engaged in any teacher lead activities, or group activities.
Evidence:
The children in the preschool area and the toddler/2year old area were not engaged in a variety of activities as required. During the inspection, both classes had self-directed free play only. Children were not engaged in any teacher lead activities, or group activities.
Plan of Correction: Childrens Lounge has received ?learn everyday curriculum? 5/20/22 We are scheduled for staff training with united way to implement daily curriculum Training is to take place 6/3/22
Going forward Staff is to follow schedule with teacher lead activities, and group activities as well as free play. Staff informed to follow schedule.
Going forward Staff is to follow schedule with teacher lead activities, and group activities as well as free play. Staff informed to follow schedule.
Standard 8VAC20-780-360-B
Based on observations and discussions with staff the facility failed to maintain compliance with this standard as required relating to moving a child who cannot move/relocate on their own.
Evidence:
A child who cannot move on their own from one position/place, as stated by staff, was not moved by staff every 30 minutes as required. The child was sitting in a special chair at the start of the inspection and remained there for approximately 45 minutes. The child was asleep for approximately 20 minutes of the 45 minutes.
Evidence:
A child who cannot move on their own from one position/place, as stated by staff, was not moved by staff every 30 minutes as required. The child was sitting in a special chair at the start of the inspection and remained there for approximately 45 minutes. The child was asleep for approximately 20 minutes of the 45 minutes.
Plan of Correction: Parents of child was notified 5/25 of licensing ratio concerns and failure to have appropriate staff for child?s supervision. Child?s parent informed for immediate dismissal due to inability to meet child?s one on ones needs.
Standard 8VAC20-780-440-B
Based on observations and discussions with staff the facility failed to maintain compliance with this standard as required relating to labeling of cots.
Evidence:
The cots the children napped on were not labeled as required.
Evidence:
The cots the children napped on were not labeled as required.
Plan of Correction: All cots labeled (completed)
Standard 8VAC20-780-500-A
Based on observations and discussions with staff the facility failed to maintain compliance with this standard as required relating to handwashing.
Evidence:
The children?s hands were not washed after lunch as required.
The children?s hands were not washed after diapering as required.
Evidence:
The children?s hands were not washed after lunch as required.
The children?s hands were not washed after diapering as required.
Plan of Correction: Staff notified of violation and the importance of maintaining public health and safety handwashing is mandatory, Staff provided one on one daily health observation in-service emphasizing handwashing times.
Standard 8VAC20-780-500-B
Based on observations and discussions with staff the facility failed to maintain compliance with this standard as required relating to running water and diaper disposal.
Evidence:
The center is using a stand-alone hand washing device that is operated by a foot pedal, and only operable with repeated foot pedal depression. However, with constant foot pedal depression the amount of water dispersed was not ?running? as required by the standard. The amount that was dispersed was only spurts of water at a time.
During diapering in the preschool aged class, the teacher used her hand to open the trashcan to dispose of the soiled diaper. The teacher did not use the foot pedal on the trashcan as required.
Evidence:
The center is using a stand-alone hand washing device that is operated by a foot pedal, and only operable with repeated foot pedal depression. However, with constant foot pedal depression the amount of water dispersed was not ?running? as required by the standard. The amount that was dispersed was only spurts of water at a time.
During diapering in the preschool aged class, the teacher used her hand to open the trashcan to dispose of the soiled diaper. The teacher did not use the foot pedal on the trashcan as required.
Plan of Correction: Water source to be replaced.
Staff notified of violation and the importance of proper disposal. Staff provided diapering in-service.
Staff notified of violation and the importance of proper disposal. Staff provided diapering in-service.
Standard 8VAC20-780-520-B
Based on observations and discussions with staff the facility failed to maintain compliance with this standard as required relating to storage of sunscreen.
Evidence:
A basket of sunscreen was under the preschool diapering table on the bottom open shelf, accessible to the children.
Evidence:
A basket of sunscreen was under the preschool diapering table on the bottom open shelf, accessible to the children.
Plan of Correction: Sunscreen and other child topicals are to be placed in locked cabinet next to changing station.
Standard 8VAC20-780-560-F
Based on observations and discussions with staff the facility failed to maintain compliance with this standard as required relating to meal requirements.
Evidence:
Milk was not served with lunch as required. Children were given juice only with lunch.
Evidence:
Milk was not served with lunch as required. Children were given juice only with lunch.
Plan of Correction: Kitchen staff informed of violation. CACFP in-service provided by Patrick from ccresources 5/25/22 to all staff.
Standard 8VAC20-780-560-M
Based on observations and discussions with staff the facility failed to maintain compliance with this standard as required relating to food service.
Evidence:
After the children in the toddler-2year old class had gotten up from the lunch table, staff handed the children sippy cups, the children were allowed to move around the classroom while drinking from the cups. Children are to be seated while drinking or eating.
Evidence:
After the children in the toddler-2year old class had gotten up from the lunch table, staff handed the children sippy cups, the children were allowed to move around the classroom while drinking from the cups. Children are to be seated while drinking or eating.
Plan of Correction: Staff will be consistent with children during meal time to encourage sitting during meal if child wonders from seat the hands must be washed and re-introduced to meal time. Staff in-services via video provided to toddler staff to maintain appropriate meal time environment. Children will not be allowed to eat or drink unless stationary.
Standard 8VAC20-780-60-A
Based on review of children records the facility failed to maintain compliance with this standard as required related to emergency contact information, parent employment information, allergies/chronic physical problems, and enrollment dates.
Evidence:
1. Child record #1 did not have a start date, emergency contact addresses, no addressing of any allergies/chronic physical problems, no employment phone number for the mother, and did not have required information addressed for the father of the child.
2. Child record #2 did not have a second emergency contact listed.
Evidence:
1. Child record #1 did not have a start date, emergency contact addresses, no addressing of any allergies/chronic physical problems, no employment phone number for the mother, and did not have required information addressed for the father of the child.
2. Child record #2 did not have a second emergency contact listed.
Plan of Correction: All children?s records pulled and completed to its entirety by parents at time of pick-up on 5/19-5/23 ; Parents were provided child?s file and completed on site, missing documents that could not be provided at this time were issued a week notice stating effective June 1st if documents are not provided children are unable to return due to standard licensing requirements and are able to return once documents are submitted.
Going forward: Childrens Lounge enrollment process has been updated, parents must provide all documentation and enrollment forms before the child is accepted, new students we will no longer have 30 days to provide a complete file. Owner/director will then update file with necessary information before filing enrollment. Created a index check list to place in all filles that can be checked off to ensure each file is complete.
Going forward: Childrens Lounge enrollment process has been updated, parents must provide all documentation and enrollment forms before the child is accepted, new students we will no longer have 30 days to provide a complete file. Owner/director will then update file with necessary information before filing enrollment. Created a index check list to place in all filles that can be checked off to ensure each file is complete.
Standard 8VAC20-780-60-C
Based on review of children records the facility failed to maintain compliance with this standard as required related to proof of birth verification.
Evidence:
Child record #2 did not have verification of review of proof of birth as required.
Evidence:
Child record #2 did not have verification of review of proof of birth as required.
Plan of Correction: All children?s records pulled and completed to its entirety by parents at time of pick-up on 5/19-5/23 ; Parents were provided child?s file and completed on site, missing documents that could not be provided at this time were issued a week notice stating effective June 1st if documents are not provided children are unable to return due to standard licensing requirements.
Going forward: Childrens Lounge enrollment process has been updated, parents must provide all documentation and enrollment forms before the child is accepted, new students we will no longer have 30 days to provide a complete file. Owner/director will then update file with necessary information before filing enrollment.
Going forward: Childrens Lounge enrollment process has been updated, parents must provide all documentation and enrollment forms before the child is accepted, new students we will no longer have 30 days to provide a complete file. Owner/director will then update file with necessary information before filing enrollment.
Standard 8VAC20-780-70
Based on review of staff records the facility failed to maintain compliance with this standard as required related to references, proof of education, job title, and hire date.
Evidence:
Upon review of staff records the following non-compliance was noted:
1. Staff records #1-#4 did not have a hire date, references, proof of education/qualifications, or job description.
2. Staff record #5 did not have a hire date, job description, or references.
Evidence:
Upon review of staff records the following non-compliance was noted:
1. Staff records #1-#4 did not have a hire date, references, proof of education/qualifications, or job description.
2. Staff record #5 did not have a hire date, job description, or references.
Plan of Correction: All staff records have been pulled and updated on 5/21/22 - 5/23/22 with hire date, job description, and references (references checked 5/23 and logged)
Required Proof of education notice provided to all staff effective June 1st without proof of education your position will be on hold staff may not return to work until documents are provided.
Required Proof of education notice provided to all staff effective June 1st without proof of education your position will be on hold staff may not return to work until documents are provided.