Inspection · 2024-09-09
Licensing Inspector
James R Basham
(804) 588-2370
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
Inspector Notes
An unannounced, on-site monitoring inspection was initiated on 9/9/2024 and completed on 9/16/2024, as a part of the licensure period. The on-site inspection began at 3:20PM and ended at 4:35PM. The inspector reviewed compliance in the areas listed above. There were 24 children present and 2 staff. The inspector reviewed 5 children?s records on-site 9/9/2024 and 2 staff records electronically 9/16/2024. This inspection included - document review (i.e. Injury logs, policies and procedures, emergency drill logs, medication administration logs, authorization forms), tour of the facility, and observations.
Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.
Standard 22.1-289.011-F
The license and any other documents required shall be posted in a conspicuous place on the licensed premises. The findings from the most recent inspection, dated 5/28/2024, were not posted in a conspicuous place on the premises.
Plan of Correction: Provider will ensure most recent inspection is posted.
Standard 22.1-289.035-B-4
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years. Staff #2, employed for 5 months, did not have documentation of requesting a central registry check from two states or a criminal history check from a different state.
Plan of Correction: Provider will ensure out of state backgrounds are submitted and received for staff.
Standard 8VAC20-780-340-F
Children under the age of 10 years shall be within actual sight and sound supervision of staff. A child, age 7 years, was observed exiting the gymnasium restroom to the playground approximately 1 minute after Staff #1 had walked away from the restroom and around a corner at the outside entrance of the school cafeteria where the restroom was not visible.
Plan of Correction: Provider will ensure sight and sound supervision of children at all times.
Standard 8VAC20-780-350-B-5
The center did not ensure that groups of school age children ages 5-12 years maintained a staff to child ratio of 1:18. Staff #1 was observed taking a group of 20 children, age 5-10 years, outside to the playground and was out of ratio for approximately 30 minutes.
Plan of Correction: Provider will ensure staff maintain correct staff to children ratios for school age groups.
Standard 8VAC20-780-500-A
Children?s hands shall be washed with soap and running water or disposable wipes after eating meals of snack. A group of ten children were observed eating snack and the children did not wash their hands with soap and running water or disposable wipes after eating.
Plan of Correction: Provider will ensure children wash hands after eating snack.
Standard 8VAC20-780-530-A
At least one staff in each classroom or area where children are present shall have within 90 days of October 13, 2021, current certification in cardiopulmonary resuscitation as appropriate to the age of the children in care and current certification in first aid. Staff #1, employed for 21 months, did not have CPR and first aid training within 90 days. Staff #2, employed 5 months, did not have CPR and first aid training within 90 days.
Plan of Correction: Provider will ensure staff receive CPR and first aid training.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. The record for Child #1 and Child #3 , enrolled 1 month, were missing 9 required components. Child #2 and Child #4, enrolled 1 month, were missing 10 components. Child #5, enrolled 1 month, was missing 8 components.
Plan of Correction: Provider will ensure children's records are complete.
Standard 8VAC20-780-70
REPEAT VIOLATION
The following staff records shall be kept for each person. The record for Staff #1, employed for 21 months, did not contain first aid and cardiopulmonary resuscitation as required by the responsibilities of the staff member. The record for Staff #2, employed for 5 months, did not contain first aid and cardiopulmonary resuscitation as required by the responsibilities of the staff member.
Plan of Correction: Provider will ensure staff records are complete.