Inspection · 2024-03-06
Date
2024-03-06
Complaint Related
No
Licensing Inspector
Susan Ellington-Sconiers
(804) 588-2368
(804) 588-2368
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
A monitoring inspection was conducted on 05/22/2024 from approximately 11:18 a.m. to 6:10 p.m. There were 120 children present and 23 staff supervising. The inspector reviewed compliance in the areas of administration, qualifications and training, physical plant, staffing and supervision, programming, medication, special care and emergencies, and nutrition. Ten child (10) records and thirteen (13) staff records were reviewed.
The information gathered during the inspection determined violations with applicable standards or law. Please sign and complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days.
Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
If you have any questions related to this inspection, please contact Susan Ellington-Sconiers, Licensing Inspector at 804-588-2368 or susan.ellington-sconiers@doe.virginia.gov.
Violations
16Standard 22.1-289.035-B-2
Based on record review, the provider failed to ensure that all applicants for employment shall
submit to fingerprinting and undergo a national criminal background check prior to
employment.
Evidence:
The record for staff S13, employed 06/23/2023 did not have results of a national criminal
background check prior to the first day of employment.
submit to fingerprinting and undergo a national criminal background check prior to
employment.
Evidence:
The record for staff S13, employed 06/23/2023 did not have results of a national criminal
background check prior to the first day of employment.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-60-B
Based on record review, the provider failed to ensure an employee not be employed until the
center has the person?s completed sworn statement.
Evidence:
The records for S5, employed 04/22/2024 and S7, employed 04/15/2024 did not contain a sworn disclosure statement.
center has the person?s completed sworn statement.
Evidence:
The records for S5, employed 04/22/2024 and S7, employed 04/15/2024 did not contain a sworn disclosure statement.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-60-C-2
Based on staff record review, the provider failed to have central registry findings within 30
days of employment.
Evidence:
The record for S2, employed 03/18/2024 did not contain findings of a central registry search.
The record for S7, employed 04/15/2024 did not contain findings of a central registry search.
The record for S8, employed 04/15/2024 did not contain findings of a central registry search.
The record for S13, employed 06/23/2023 did not contain findings of a central registry search.
days of employment.
Evidence:
The record for S2, employed 03/18/2024 did not contain findings of a central registry search.
The record for S7, employed 04/15/2024 did not contain findings of a central registry search.
The record for S8, employed 04/15/2024 did not contain findings of a central registry search.
The record for S13, employed 06/23/2023 did not contain findings of a central registry search.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-130-A
Based on child record review, the provider failed to obtain documentation that each child
has received the immunizations required by the State Board of Health before the child can
attend the center.
Evidence:
The record for C2, enrolled 09/10/2023 documented immunizations on 10/30/2023.
The record for C3, enrolled 08/27/2023 documented immunizations on 08/29/2023.
has received the immunizations required by the State Board of Health before the child can
attend the center.
Evidence:
The record for C2, enrolled 09/10/2023 documented immunizations on 10/30/2023.
The record for C3, enrolled 08/27/2023 documented immunizations on 08/29/2023.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-130-E
8VAC20-780-(2)-130-E
Based on child record review, the provider failed to obtain documentation of additional
immunizations once every six months for children under the age of two years.
Evidence:
The record for C2, under the age of 2 years did not contain additional immunizations due within six months of immunizations in the record dated 10/30/2023.
The record for C3, under the age of 2 years did not contain additional immunizations due within six months of immunizations in the record dated 08/29/2023.
The record for C5, under the age of 2 years did not contain additional immunizations due within six months of immunizations in the record dated 06/26/2023.
The record for 6, under the age of 2 years did not contain additional immunizations due within six months of immunizations in the record dated 01/11/2023.
Based on child record review, the provider failed to obtain documentation of additional
immunizations once every six months for children under the age of two years.
Evidence:
The record for C2, under the age of 2 years did not contain additional immunizations due within six months of immunizations in the record dated 10/30/2023.
The record for C3, under the age of 2 years did not contain additional immunizations due within six months of immunizations in the record dated 08/29/2023.
The record for C5, under the age of 2 years did not contain additional immunizations due within six months of immunizations in the record dated 06/26/2023.
The record for 6, under the age of 2 years did not contain additional immunizations due within six months of immunizations in the record dated 01/11/2023.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-140-A
Based on child record review, the provider failed to ensure 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:
The record for C2, enrolled 09/10/2023 contained a physical examination report dated
10/30/2023.
Evidence:
The record for C2, enrolled 09/10/2023 contained a physical examination report dated
10/30/2023.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-160-A
Based on staff record review, the provider failed to ensure that seven of thirteen staff submit
documentation of a negative tuberculosis screening at the time of employment or documentation completed within the last 30 calendar days of the date of employment.
Evidence:
The record for S1, employed 03/04/2024 did not document a tuberculosis (TB) screening.
The record for S3, employed 05/20/2024 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 03/06/2024.
The record for S7, employed 04/15/2024 did not document a tuberculosis (TB) screening.
The record for S8, employed 04/15/2024 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 10/27/2023.
The record for S9, employed 10/02/2023 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 11/18/2023.
The record for S11, employed 03/29/2023 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 10/26/2023.
The record for S13, employed 06/23/2023 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 08/18/2022.
documentation of a negative tuberculosis screening at the time of employment or documentation completed within the last 30 calendar days of the date of employment.
Evidence:
The record for S1, employed 03/04/2024 did not document a tuberculosis (TB) screening.
The record for S3, employed 05/20/2024 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 03/06/2024.
The record for S7, employed 04/15/2024 did not document a tuberculosis (TB) screening.
The record for S8, employed 04/15/2024 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 10/27/2023.
The record for S9, employed 10/02/2023 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 11/18/2023.
The record for S11, employed 03/29/2023 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 10/26/2023.
The record for S13, employed 06/23/2023 did not document a tuberculosis (TB) screening
within the required time frame. The screening was completed 08/18/2022.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-210-A
Based on record review, the provider failed to ensure that program leaders shall meet all the required qualifications.
Evidence:
Staff records for S1, employed 03/04/2024, S2 employed 03/18/2024, and S10, employed 08/21/2023 did not have documentation to demonstrate how the staff meets program leader qualifications.
Evidence:
Staff records for S1, employed 03/04/2024, S2 employed 03/18/2024, and S10, employed 08/21/2023 did not have documentation to demonstrate how the staff meets program leader qualifications.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-240-B
Based on staff record review, the provider failed to ensure that staff completed orientation
training required by 8VAC20-780-(3)-240-C prior to the staff member working alone with
children and no later than seven days of the date of assuming job responsibilities.
Evidence:
The staff records for S2, employed 03/18/2024, S4, employed 12/21/2023, S5, employed 04/22/2024, S6, employed 04/22/2024, S7, employed 04/15/2024, and S8, 04/15/2024 did not contain documentation of orientation.
training required by 8VAC20-780-(3)-240-C prior to the staff member working alone with
children and no later than seven days of the date of assuming job responsibilities.
Evidence:
The staff records for S2, employed 03/18/2024, S4, employed 12/21/2023, S5, employed 04/22/2024, S6, employed 04/22/2024, S7, employed 04/15/2024, and S8, 04/15/2024 did not contain documentation of orientation.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-240-E
Based on staff record review, the provider failed to ensure that staff within 30 days of the
first day of employment complete orientation training in first aid and cardiopulmonary
resuscitation (CPR).
Evidence:
Staff records for S1, S2, S3, S4, S5, S6, S7, S8 did not document the orientation training in first aid and CPR.
first day of employment complete orientation training in first aid and cardiopulmonary
resuscitation (CPR).
Evidence:
Staff records for S1, S2, S3, S4, S5, S6, S7, S8 did not document the orientation training in first aid and CPR.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-40-M
Based on observation, the center failed to maintain a current written list of all children allergies, sensitivities, and dietary restrictions that is dated and kept confidential.
Evidence:
Licensing inspector observed the child allergy lists posted in Pre-K and the Discovery Pre-School 2 classrooms were dated for February 2024 and May 2024. The Pre-K classroom list was not current.
Evidence:
Licensing inspector observed the child allergy lists posted in Pre-K and the Discovery Pre-School 2 classrooms were dated for February 2024 and May 2024. The Pre-K classroom list was not current.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-420-E-3
Based on child record review, the provider failed to document at least annually parent
confirmation that the required information in the child?s record is up to date.
Evidence:
The records for child, C4 enrolled 11/29/2022, C6, enrolled 01/16/2023, C7, enrolled 04/24/2023, C8, enrolled 11/28/2022, C9, enrolled 12/05/2022 did not document annual confirmation of required information in the record.
confirmation that the required information in the child?s record is up to date.
Evidence:
The records for child, C4 enrolled 11/29/2022, C6, enrolled 01/16/2023, C7, enrolled 04/24/2023, C8, enrolled 11/28/2022, C9, enrolled 12/05/2022 did not document annual confirmation of required information in the record.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-510-L
Based on observation, the provider failed to ensure that a medication was kept in a locked place.
Evidence:
Licensing inspector observed a bottle of Infant Tylenol on the program directors? desk and the office door was open and accessible to children.
Evidence:
Licensing inspector observed a bottle of Infant Tylenol on the program directors? desk and the office door was open and accessible to children.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-560-J
Based on observation, the provider did not ensure that tables be sanitized before and after
food being consumed by children.
Evidence:
Licensing inspector observed the DSP-1 classroom children having a snack and the tables not being sanitized afterwards before starting a craft activity.
food being consumed by children.
Evidence:
Licensing inspector observed the DSP-1 classroom children having a snack and the tables not being sanitized afterwards before starting a craft activity.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-60-A
Based on child record review, the provider failed to ensure that one of ten contained required documentation.
Evidence:
The record for child, C7, enrolled 04/24/2023 did not contain documentation of viewing proof of the child?s identity and age.
Evidence:
The record for child, C7, enrolled 04/24/2023 did not contain documentation of viewing proof of the child?s identity and age.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-70
Based on record review, the provider did not keep the required records for three of thirteen staff.
Evidence:
The records for S2, employed 03/18/2024, S5, employed 04/22/2024, and S13, employed 06/23/2023 did not document information about any health problems that may interfere with fulfilling the job responsibilities and emergency contacts.
Evidence:
The records for S2, employed 03/18/2024, S5, employed 04/22/2024, and S13, employed 06/23/2023 did not document information about any health problems that may interfere with fulfilling the job responsibilities and emergency contacts.
Plan of Correction: Not available online. Contact Inspector for more information.