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Lynchburg Community Action Group - Madison Heights

Inspection · 2023-03-09

Date
2023-03-09
Complaint Related
Yes
Licensing Inspector
Shanae Vaughn
(276) 608-4267
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

Inspector Notes

An unannounced complaint inspection was conducted on-site on 03/09/2023 and concluded with an additional record review at the home office on 03/09/2023. There were 27 children, ages 3 years- 5 years, and 4 staff members present during the inspection. The inspector reviewed compliance in the areas of administration, staff qualifications and trainings, staffing and supervision, physical plant, programs, emergencies and nutrition. The children were observed during arrival, mealtime, teacher directed activities, self-directed activities, and self-chosen tasks. Staff were interviewed and total of 3 children?s records, and 5 staff records were reviewed. The inspector arrived for the onsite inspection at 8:00 am and departed at 9:15 am.
The information gathered during the course of the investigation did not support the complaint and therefore the complaint was determined to be not valid. The information gathered during the course of the investigation determined non-compliance with applicable standards or law and violations unrelated to the complaint were documented on the violation notice issued to the provider.

Violations

3
Standard 22.1-289.035-A
Based on record review and interviews with staff, the center failed to ensure that all employees shall undergo a background check in accordance the Code of Virginia prior to employment or beginning to serve as a volunteer and every five years thereafter.
1. The most recent criminal record check-eligibility letter in the record for Staff 2 was dated 02/12/2018. There was no repeat background check document obtained for 2023. Staff 7 confirmed this documentation was not available.
2. The most recent criminal record check-eligibility letter in the record for Staff 3 was dated 02/07/2018. There was no repeat background check document obtained for 2023. Staff 7 confirmed this documentation was not available.
3. The most recent criminal record check-eligibility letter in the record for Staff 4 was dated 02/07/2018. There was no repeat background check document obtained for 2023. Staff 7 confirmed this documentation was not available.
4. The most recent search of the central registry in the record for Staff 4 was dated 10/24/2017. There was no repeat search document obtained for 2022. Staff 7 confirmed this documentation was not available.
Plan of Correction: Provider will obtain information.
Standard 8VAC20-780-130-A
Based on record review and interviews with staff, the center failed to obtain documentation that each child has received the immunization required by the State Board of Health before the child can attend the center.
Evidence:
1. The record for Child 1 indicated the first date of attendance as 09/06/2022. The immunization record was not available for review. Staff 1 and 3 confirmed this documentation was not available for review.
2. The record for Child 2 indicated the first date of attendance as 10/26/2022. The immunization record was not available for review. Staff 1 and 3 confirmed this documentation was not available for review.
3. The record for Child 3 indicated the first date of attendance as 09/01/2022. The immunization record was not available for review. Staff 1 and 3 confirmed this documentation was not available for review.
Plan of Correction: Provider will obtain information and ensure it is available for review.
Standard 8VAC20-780-140-A
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:
1. The record for Child 1 indicated the first date of attendance as 09/06/2022. There was no documentation of a physical examination available for review. Staff 1 and 3 confirmed this documentation was not available for review.
2. The record for Child 2 indicated the first date of attendance as 10/26/2022. There was no documentation of a physical examination available for review. Staff 1 and 3 confirmed this documentation was not available for review.
3. The record for Child 3 indicated the first date of attendance as 09/01/2022. There was no documentation of a physical examination available for review. Staff 1 and 3 confirmed this documentation was not available for review.
Plan of Correction: Provider will obtain information and ensure it is available for review.
View original record on Virginia Department of Social Services