Inspection · 2022-10-06
Date
2022-10-06
Complaint Related
No
Licensing Inspector
Todd Scott
(276) 608-3749
(276) 608-3749
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.
8VAC2O-820 THE LICENSE.
8VAC2O-820 THE LICENSING PROCESS,
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced non-mandated 60 day inspection was completed on 10/06/2022 by two inspectors. There were 22 children present with 4 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. There was one repeat violation and one violation had been corrected. A total of 4 child records and 5 staff records were reviewed. The inspection started at 10:25 a.m. and concluded at 1:00 p.m.
As per 8VAC20-820-80, when the conditional period is over, the facility or agency must substantially meet the standards or be denied a license.
The violation notice was amended 10/21/2022.
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.
Violations
19Standard 8VAC20-770-60-B
Based on record review, the center employed a person before a a sworn statement had been completed.
Evidence:
Staff record #3 was hired 8/16/22 and the sworn statement was dated 9/6/22 by staff #3.
Evidence:
Staff record #3 was hired 8/16/22 and the sworn statement was dated 9/6/22 by staff #3.
Plan of Correction: Dates will be double checked, and better organization to prevent misplacing paperwork and that sworn statements ae signed and dated before hire date.
Standard 8VAC20-780-240-A
Based on record review, the center failed to have staff complete orientation prior to staff working alone with children and no later than seven days of the date of assuming job responsibilities.
Evidence:
1. Staff #1, hire date 08/15/2022, and staff #2, hire date 09/15/2022 had no documentation of orientation. 2. Both staff #1 and #2 were observed working on the date of the inspection.
Evidence:
1. Staff #1, hire date 08/15/2022, and staff #2, hire date 09/15/2022 had no documentation of orientation. 2. Both staff #1 and #2 were observed working on the date of the inspection.
Plan of Correction: I will personally recheck files to be sure they include all required. All staff has an extensive training prior to working.
Standard 8VAC20-780-240-D
Based on review of policies and procedures, the center failed to provide written policies to staff prior to working alone with children and within seven days of the first day of employment the following policies:
Evidence:
1. There were no written policies required by this section that include: procedures for supervising a child who may arrive after scheduled classes or activities including field trips have begun; 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; 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.
Evidence:
1. There were no written policies required by this section that include: procedures for supervising a child who may arrive after scheduled classes or activities including field trips have begun; 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; 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.
Plan of Correction: Will include an addendum to our training guide to sate we don't do field trips and to include a written policy that we sign children in and out on our attendance sheet. Will also include we do not transport children to or from the center and we conduct head counts when going outside and or coming in from outside
Standard 8VAC20-780-245-K
Based on record review and interview, the center failed to have a staff person present who had daily health observation training.
Evidence:
1. Records were reviewed and there was no documentation of any staff having daily health observation training.
Staff #5 stated she was currently working to complete the training.
Evidence:
1. Records were reviewed and there was no documentation of any staff having daily health observation training.
Staff #5 stated she was currently working to complete the training.
Plan of Correction: Daily observation training will be completed by staff.
Standard 8VAC20-780-270-A
Based on observation, the center failed to maintain the areas and equipment inside and outside in a clean, safe, and operable condition.
Evidence:
1. There is a broken plastic brown table on the playground turned upside down with five exposed rusty nails.
Evidence:
1. There is a broken plastic brown table on the playground turned upside down with five exposed rusty nails.
Plan of Correction: The sand table that had fell off has been removed from the playground until it can get safely screwed back into the table.
Standard 8VAC20-780-290-A-3
Based on observation, the center failed to have electrical outlets with a protective cover that are of size that cannot be swallowed by children.
Evidence:
There is an electrical outlet outside the side door leading to the playground that does not have a protective cover.
Evidence:
There is an electrical outlet outside the side door leading to the playground that does not have a protective cover.
Plan of Correction: Replace the one plug in cover that was missing.
Standard 8VAC20-780-310-C
Based on observation, the center failed to have a separate playground for infants and toddlers at least 25 sq. feet of unpaved surface per infant /toddler on the outdoor area at any one time.
Evidence:
1. The center had approximately 175 sq. feet of mats in place for infants and toddlers outside. The center has 12 infants and toddlers in care therefore 300 sq. feet of unpaved surface is required for the outdoor area.
Evidence:
1. The center had approximately 175 sq. feet of mats in place for infants and toddlers outside. The center has 12 infants and toddlers in care therefore 300 sq. feet of unpaved surface is required for the outdoor area.
Plan of Correction: Additional mats have been delivered 10/17/22 and will be installed by 10/18/2022.
Standard 8VAC20-780-330-B
330.B:
Based on observation, the center failed to ensure where playground equipment is provided, that there was resilient surfacing that complies with the minimum safety standards.
Evidence:
1. There were two slides on the playground. Staff #5 verified slide #1 measured 13 inches high and slide #2 measured 16.5 inches high that were over rubber mats measuring ? inch. One inch mats are required for the entire six feet fall zone area. 2. Staff #5 verified the thickness of the mats based on the order documentation for the mats.
Slide #1 had approximately five inches of a fall zone area on one side and 24 inches on another side; at the bottom of the slide shoot there was approximately one inch of fall zone area. Climbing equipment and slides are required to have resilient surfacing six feet on all sides, and four feet plus the height of the slide in front of the slide chute.
3. Slide #2 had approximately five inches of a fall zone area on one side and 24 inches on another side and between one to two inches at the end of the slide shoot. Climbing equipment and slides are required to have resilient surfacing six feet on all sides, and four feet plus the height of the slide in front of the slide chute.
Based on observation, the center failed to ensure where playground equipment is provided, that there was resilient surfacing that complies with the minimum safety standards.
Evidence:
1. There were two slides on the playground. Staff #5 verified slide #1 measured 13 inches high and slide #2 measured 16.5 inches high that were over rubber mats measuring ? inch. One inch mats are required for the entire six feet fall zone area. 2. Staff #5 verified the thickness of the mats based on the order documentation for the mats.
Slide #1 had approximately five inches of a fall zone area on one side and 24 inches on another side; at the bottom of the slide shoot there was approximately one inch of fall zone area. Climbing equipment and slides are required to have resilient surfacing six feet on all sides, and four feet plus the height of the slide in front of the slide chute.
3. Slide #2 had approximately five inches of a fall zone area on one side and 24 inches on another side and between one to two inches at the end of the slide shoot. Climbing equipment and slides are required to have resilient surfacing six feet on all sides, and four feet plus the height of the slide in front of the slide chute.
Plan of Correction: The play equipment has been removed.
Standard 8VAC20-780-350-F
Based on a review of written policies and procedures, the center failed to develop and implement a written policy and procedure that describes how the center will ensure that each group of children receives care of consistent staff or team of staff members.
Evidence:
The center did not have a written policy and procedure that describes how the center will ensure that each group of children receives care of consistent staff or team of staff members.
Evidence:
The center did not have a written policy and procedure that describes how the center will ensure that each group of children receives care of consistent staff or team of staff members.
Plan of Correction: A policy and procedure will be written as required with our counting policy and ratio standards added.
Standard 8VAC20-780-40-K
Based on review of written policies and procedures, the center failed to have written procedures for prevention of shaken baby syndrome or abusive head trauma, including coping with crying baby, safe sleeping practices, and sudden infant death syndrome awareness.
Evidence:
The written policies reviewed did not have the required written procedures included.
Evidence:
The written policies reviewed did not have the required written procedures included.
Plan of Correction: These topics are discussed often, and will continue to training staff on these procedure and will include the written procedures in the employee policy handbook.
Standard 8VAC20-780-420-A
The center failed to have all the required information provided to parents in writing before the child's first day of attendance.
Evidence:
1. The parent handbook was missing policies on transportation, arrival and departure of children including procedures for verifying that only persons authorized by the parent are allowed to pick up the child, picking up children after closing, and when a child is not picked up for emergency situations including inclement weather or natural or man-made disasters; sunscreen and insect repellent, the custodial parent's right to be admitted t the center as required by 22.1-289.054 of the Code of Virginia; policy for communicating an emergency situation with parents; general daily schedules for the age of the enrolling child; and food policies.
Evidence:
1. The parent handbook was missing policies on transportation, arrival and departure of children including procedures for verifying that only persons authorized by the parent are allowed to pick up the child, picking up children after closing, and when a child is not picked up for emergency situations including inclement weather or natural or man-made disasters; sunscreen and insect repellent, the custodial parent's right to be admitted t the center as required by 22.1-289.054 of the Code of Virginia; policy for communicating an emergency situation with parents; general daily schedules for the age of the enrolling child; and food policies.
Plan of Correction: Polices will be written and added to the parent handbook. Parents will be asked to sign and acknowledgement of the updated policies.
Standard 8VAC20-780-430-G
Based on observation, the center failed to ensure that the climbing portions of indoor slides and climbing equipment 36 inches or more were located over resilient surfacing.
Evidence:
A dome climbing structure in the preschool room was 48 inches high and did not have resilient surfacing underneath.
Evidence:
A dome climbing structure in the preschool room was 48 inches high and did not have resilient surfacing underneath.
Plan of Correction: Equipment will be taken apart and removed.
Standard 8VAC20-780-440-B
Based on observation and interview, the center failed to have rest mats identified for use by a specific child.
Evidence:
Rest mats were observed being used with no identification. Staff verified that the mats were not identified for use by a specific child.
Evidence:
Rest mats were observed being used with no identification. Staff verified that the mats were not identified for use by a specific child.
Plan of Correction: Rest mats will be marked with child's name with a permanent marker.
Standard 8VAC20-780-560-F
Based on observation, the center failed to have a menu for the current one-week period.
Evidence:
The menu posted was dated for the week of 09/26/22. The date of the inspection was 10/6/22.
Evidence:
The menu posted was dated for the week of 09/26/22. The date of the inspection was 10/6/22.
Plan of Correction: Making sure the new menu is posted each Friday, prior to Monday of he following week.
Standard 8VAC20-780-570-E
Based on observation, the center failed to have prepared infant formula labeled with the child?s name and dated.
Evidence:
An infant was observed being fed by staff and the bottle was not labeled with a child?s name or dated.
Evidence:
An infant was observed being fed by staff and the bottle was not labeled with a child?s name or dated.
Plan of Correction: Bottle lables have been purchase and begun to use immediately.
Standard 8VAC20-780-60-A
Based on record review, the center failed to maintain a record for each child enrolled with all the required information.
Evidence:
1. Child #1?s record did not contain the following: first day of attendance; parent(s) work phone number and place of employment; parent(s) name, address, and home number; name, address, and phone number of two emergency contacts; names of persons authorized to pick up the child; allergies and intolerance for medication or any other substance; action to take in an emergency; previous child day care and schools attended by child; documentation of written agreement between parent and the center by the first day of the child?s attendance.
2. Child #2?s record did not contain the following: first day of attendance; previous child day care and schools attended by child; documentation of written agreement between parent and the center by the first day of the child?s attendance. An allergy was listed on the enrollment form for child #2, but no action to take in an emergency situation was listed.
3. Child #3?s record did not contain the following: first day of attendance; name, address, and phone number of two emergency contacts; previous child day care and schools attended by child.
4. Child #4?s record did not contain the following: first day of attendance; previous child day care and schools attended by child.
Evidence:
1. Child #1?s record did not contain the following: first day of attendance; parent(s) work phone number and place of employment; parent(s) name, address, and home number; name, address, and phone number of two emergency contacts; names of persons authorized to pick up the child; allergies and intolerance for medication or any other substance; action to take in an emergency; previous child day care and schools attended by child; documentation of written agreement between parent and the center by the first day of the child?s attendance.
2. Child #2?s record did not contain the following: first day of attendance; previous child day care and schools attended by child; documentation of written agreement between parent and the center by the first day of the child?s attendance. An allergy was listed on the enrollment form for child #2, but no action to take in an emergency situation was listed.
3. Child #3?s record did not contain the following: first day of attendance; name, address, and phone number of two emergency contacts; previous child day care and schools attended by child.
4. Child #4?s record did not contain the following: first day of attendance; previous child day care and schools attended by child.
Plan of Correction: A focus will be put on new student files and that they contain all the required info. before getting files in the cabinet. More detailed training for the aide's that help out with the files, on how important organization and being thorough with each file. Pull the files that are missing information and have them corrected and updated.
Standard 8VAC20-780-70
Based on record review, the center failed to have the required information in a record for each staff person.
Evidence:
1. Staff record #1 did not have the following: an address and telephone number of a person to be notified in an emergency; two references (required prior to employment); information about any health problems that may interfere with fulfilling the job responsibilities; or documentation of qualifications or experience required by the job position that was documented in the record.
2. Staff record #2 did not have the following: an address and telephone number of a person to be notified in an emergency; two references (required prior to employment); information about any health problems that may interfere with fulfilling the job responsibilities; or documentation of qualifications or experience required by the job position that was documented in the record.
3. Staff record #3 did not have the following: an address, and telephone number of a person to be notified in an emergency; information about any health problems that may interfere with fulfilling the job responsibilities; or documentation of qualifications or experience in the file.
4. Staff record #4 did not have the following: an address and telephone number of a person to be notified in an emergency; two references (required prior to employment); and information about any health problems that may interfere with fulfilling the job responsibilities.
5. Staff record #5 did not have the following: an address and telephone number of a person to be notified in an emergency; two references (required prior to employment); and information about any health problems that may interfere with fulfilling the job responsibilities.
Evidence:
1. Staff record #1 did not have the following: an address and telephone number of a person to be notified in an emergency; two references (required prior to employment); information about any health problems that may interfere with fulfilling the job responsibilities; or documentation of qualifications or experience required by the job position that was documented in the record.
2. Staff record #2 did not have the following: an address and telephone number of a person to be notified in an emergency; two references (required prior to employment); information about any health problems that may interfere with fulfilling the job responsibilities; or documentation of qualifications or experience required by the job position that was documented in the record.
3. Staff record #3 did not have the following: an address, and telephone number of a person to be notified in an emergency; information about any health problems that may interfere with fulfilling the job responsibilities; or documentation of qualifications or experience in the file.
4. Staff record #4 did not have the following: an address and telephone number of a person to be notified in an emergency; two references (required prior to employment); and information about any health problems that may interfere with fulfilling the job responsibilities.
5. Staff record #5 did not have the following: an address and telephone number of a person to be notified in an emergency; two references (required prior to employment); and information about any health problems that may interfere with fulfilling the job responsibilities.
Plan of Correction: A staff info. sheet that includes all emergency info., contact info., and medical info. on each employee has been created. Adding the required refence information on each staff member prior to hiring date.
Standard 8VAC20-820-120-E-2
Based on observation, the center failed to ensure that the findings from the most recent inspection at the facility were posted.
Evidence:
The violation notice which would show the most recent findings at the facility dated 8/8/2022 was not posted.
Evidence:
The violation notice which would show the most recent findings at the facility dated 8/8/2022 was not posted.
Plan of Correction: The inspection notice will be posted in the future when received.
Standard 8VAC20-820-160-A-1
Based on record review, the center failed to have each staff member submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence:
1. Staff #3 was hired 8/16/2022 and the TB screening was completed 8/17/2022. Staff #4 was hired 9/12/2022 and the TB screening was completed 9/14/2022.
Evidence:
1. Staff #3 was hired 8/16/2022 and the TB screening was completed 8/17/2022. Staff #4 was hired 9/12/2022 and the TB screening was completed 9/14/2022.
Plan of Correction: Employee wrote down the incorrect start date. Staff will be more careful looing at the dates on all administrative paperwork, ensure the correct dates are inputted.