Inspection · 2023-12-05
Date
2023-12-05
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
22.1 Background Checks Code
8VAC20-790 Physical Plant
32.1 Report by person other than physician
8VAC20-790 Staffing & Supervision
63.2 Child abuse and neglect
8VAC20-790 Programs
8VAC20-790 Introduction
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Administration
8VAC20-790 Special Services
8VAC20-790 Staff Qualifications & Training
Inspector Notes
Licensing Inspector conducted an unannounced Religiously Exempt Code Annual Inspection on December 5, 2023. There were 13 children ages 4 months to 4 years old present under the direct care of 5 staff. The Licensing Inspector reviewed 4 children?s records and 5 staff records, along with any requested program records submitted by the facility to determine if required documentation was complete.
Information gathered during the inspection determined non-compliances with applicable standards or law and violations were documented on the violation notice issued to the program.
Violations
6Standard 22.1-289.031-A-4
Based on record review, the Center failed to ensure every person in a supervisory position has been certified by a practicing physician or physician assistant to be free from any disability which would prevent them from caring for children under their supervision.
EVIDENCE:
1. The annual health exam for Staff #1 was dated 3/28/2022 and has expired. Staff #1 was observed working with the children during the inspection.
2. The annual health exam for Staff #2 was dated 4/8/2022 and has expired. Staff #2 was observed working with the children during the inspection.
3. The annual health exam for Staff #3 was dated 3/4/2022 and has expired. Staff #3 was observed working with the children during the inspection.
4. Staff #5 did not have a completed health exam in the record. Staff #5 was observed working with the children during the inspection.
EVIDENCE:
1. The annual health exam for Staff #1 was dated 3/28/2022 and has expired. Staff #1 was observed working with the children during the inspection.
2. The annual health exam for Staff #2 was dated 4/8/2022 and has expired. Staff #2 was observed working with the children during the inspection.
3. The annual health exam for Staff #3 was dated 3/4/2022 and has expired. Staff #3 was observed working with the children during the inspection.
4. Staff #5 did not have a completed health exam in the record. Staff #5 was observed working with the children during the inspection.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.031-A-8
Based on record review, the Center did not have at least one staff person certified in first aid and cardiopulmonary resuscitation present at the center whenever children are present.
EVIDENCE:
There was not at least 1 staff person present who has current CPR and First Aid certification. Staff #2 first aid and CPR certification expired 11/2022.
EVIDENCE:
There was not at least 1 staff person present who has current CPR and First Aid certification. Staff #2 first aid and CPR certification expired 11/2022.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.031-B-2
Based on record review, the Center failed to ensure each staff member completed required Fingerprint Background Check before date of employment.
EVIDENCE:
1. Record for Staff #1 did not include a fingerprint background check. Director stated the date of hire was in July 2022 for Staff #1.
2. Record for Staff #4 did not include a fingerprint background check. Director stated the date of hire was in August 2023 for Staff #4.
EVIDENCE:
1. Record for Staff #1 did not include a fingerprint background check. Director stated the date of hire was in July 2022 for Staff #1.
2. Record for Staff #4 did not include a fingerprint background check. Director stated the date of hire was in August 2023 for Staff #4.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.049-A
REPEAT VIOLATION
Based on record review, the Center, upon enrollment of a child, failed to require information regarding proof of the child?s age and identity.
EVIDENCE:
Record for Child #1 (enrollment date was not documented), Child #2 (enrollment date 9/5/2023) and Child #3 (enrollment date 8/9/2022) did not include evidence of the child?s proof of age and identity.
Based on record review, the Center, upon enrollment of a child, failed to require information regarding proof of the child?s age and identity.
EVIDENCE:
Record for Child #1 (enrollment date was not documented), Child #2 (enrollment date 9/5/2023) and Child #3 (enrollment date 8/9/2022) did not include evidence of the child?s proof of age and identity.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.058
Based on inspection, the Center failed to have a carbon monoxide detector in each building built before 2015 and houses a child day program that serves preschool children.
EVIDENCE:
A Carbon Monoxide detector has not been installed.
EVIDENCE:
A Carbon Monoxide detector has not been installed.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-40-D-2
Based on record review, the Center failed to have Sworn Disclosure Background Check completed for each staff person before date of employment; Center failed to have Central Registry Background Check completed for each staff person by the end of the 30th day of employment.
EVIDENCE:
1. Record for Staff #5 did not include a sworn disclosure background check. Date of hire for Staff #4 was 7/7/2022.
2. Record for Staff #4 did not include a central registry background check. Director stated the date of hire was in August 2023.
EVIDENCE:
1. Record for Staff #5 did not include a sworn disclosure background check. Date of hire for Staff #4 was 7/7/2022.
2. Record for Staff #4 did not include a central registry background check. Director stated the date of hire was in August 2023.
Plan of Correction: Not available online. Contact Inspector for more information.