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Celebree School of Alexandria

Inspection · 2024-08-15

Date
2024-08-15
Complaint Related
Yes
Licensing Inspector
Shahana Green
(571) 423-6735
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 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
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Program
VAC20-790 Staffing & Supervision
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services

Inspector Notes

An unannounced inspection was initiated on 8/15/2024 and completed on 9/23/2024 in response to a complaint received by the licensing office on 8/14/2024 relating to allegations of supervision, staff qualifications/training and staff to child ratios. The inspector reviewed 2 children?s records and 2 staff records on-site on 8/15/2024. This inspection included document review, tour of the facility, interviews, and observations. The preponderance of evidence gathered during the investigation supports the allegations; therefore, the complaint is determined to be valid. Information gathered during the inspection determined non-compliance with applicable standards or law and the violations are documented on the violation notice issued to the program.

Violations

4
Standard 22.1-289.035-B-4
**Repeat Violation**
Based on a review of staff records, 1 out of 2 staff did not authorize the child day center
described in subsection A to obtain a copy of the results of a sex offender registry check, and a search of the child abuse and neglect registry or equivalent registry from any state in which the individual has resided in the preceding five years.

Evidence:
1. Staff #2 did not have documentation of a sex offender registry check and a search of the child abuse and neglect registry or equivalent registry from any state in which the individual has resided in the preceding five years at the time of the inspection.
Plan of Correction: To ensure full compliance, we are now implementing stricter protocols to obtain out-of-state background checks prior to any employee?s onboarding. We are also adding going through the completed file during onboarding. Additionally, the staff member tied to this violation is no longer employed with Celebree, and all remaining staff files are now fully compliant.
Standard 8VAC20-770-40-D-1-b
Based on a review of staff records, all staff did not have a search of the central registry record check before 30 days of employment at the facility ends.

Evidence:
1. Staff #2 did not have documentation on file of a central registry record check for Virginia and had been employed more than 30 days at the facility.
Plan of Correction: Moving forward, we will ensure that all central registry clearances are obtained prior to staff enrollment. All required files will be updated and completed by Sunday, September 22, 2024.
Standard 8VAC20-780-160-A
Based on a review of staff records, 2 out of 2 staff members did not submit documentation of a negative tuberculosis screening.

Evidence:
1. Staff #1 did not have documentation of a negative tuberculosis screening on file at the time of the inspection.
2. Staff #2 did not have documentation of a negative tuberculosis screening on file at the time of the inspection.
Plan of Correction: We will guarantee that all staff members have up-to-date TB screenings on file. Moving forward, the TB screening form will be included in the staff welcome email to ensure they bring it on day 1. This process is already in motion, and we will finalize all documentation by Sunday, September 22, 2024.
Standard 8VAC20-780-70
Based on a review of staff records, 2 out of 2 staff records did not contain the required information for each staff person.

Evidence:
1. Staff #1 was missing an emergency contact, 2 of 2 required character references, staff orientation, and proof of education/qualifications.
2. Staff #2 was missing 2 of 2 required character references, and staff orientation.
Plan of Correction: To maintain consistency and avoid any future discrepancies, we are creating a detailed Excel document to track and update staff records in real-time. This system will be operational by Sunday, September 22, 2024, ensuring that all staff files remain current and accurate. Additionally, the staff member tied to this violation is no longer employed with Celebree, and all remaining staff files are now fully compliant.
View original record on Virginia Department of Social Services