Inspection · 2024-02-20
Date
2024-02-20
Complaint Related
No
Licensing Inspector
Brandie Viscayda
(757) 636-3427
(757) 636-3427
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
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
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 monitoring inspection was conducted on February 20, 2024 from 10:00am to approximately 2:00pm. At the time of the inspection there were 35 children in care and 8 staff. The inspectors were able to observe children participating in free play both indoors and outdoors, handwashing, room transitions, lunch and naptime. Records were reviewed for 5 children and 4 staff members. Evacuation drills, emergency supplies and other required records and postings were also reviewed. After review, medications are not administered at the center and transportation is not provided. The information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice and discussed with the owner and administrator during the exit interview.
Violations
13Standard 22.1-289.035-B-2
Based on record review and interview, it was determined that the center did not ensure that the criminal history records check is received prior to the first day of employment.
Evidence:
1. Staff #5 that started working with children in February 2024 did not have in their record the results of their Criminal history record check prior to the first day of employment.
a. Staff #5 was present in the classroom during the inspection.
2. Staff #1, Director, was unable to produce the required Criminal history background checks for Staff #5.
Evidence:
1. Staff #5 that started working with children in February 2024 did not have in their record the results of their Criminal history record check prior to the first day of employment.
a. Staff #5 was present in the classroom during the inspection.
2. Staff #1, Director, was unable to produce the required Criminal history background checks for Staff #5.
Plan of Correction: ? The Director will ensure that the completed staff central registry check and criminal history checked is completed before the first day of employment and checked annually.
Standard 8VAC20-770-60-C-2
REPEAT VIOLATION
Based on record review and interview, it was determined that the center did not ensure that central registry results by the end of the 30th day of employment was completed. Repeat violation.
Evidence:
1. Two of the four staff records that were reviewed did not have the Virginia Central Registry results by the end of the 30th day of employment.
a. Staff #3 was working with children at the center starting 10/25/2023.
b. Staff #4 has a sworn statement dated 1/04/2024 and started working at that time with children. There is no documentation of central registry checks in their record.
2. Staff #1 was unable to produce the documentation that the Virginia Central Registry results were completed for two of the four staff records reviewed.
Based on record review and interview, it was determined that the center did not ensure that central registry results by the end of the 30th day of employment was completed. Repeat violation.
Evidence:
1. Two of the four staff records that were reviewed did not have the Virginia Central Registry results by the end of the 30th day of employment.
a. Staff #3 was working with children at the center starting 10/25/2023.
b. Staff #4 has a sworn statement dated 1/04/2024 and started working at that time with children. There is no documentation of central registry checks in their record.
2. Staff #1 was unable to produce the documentation that the Virginia Central Registry results were completed for two of the four staff records reviewed.
Plan of Correction: ? The Director will ensure that the completed staff central registry check and criminal history checked is completed before the first day of employment and checked annually.
Standard 8VAC20-780-160-A
Based on record review and interview, it was determined that the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children.
Evidence:
1. Staff #5 that started working with children in February 2024, did not have documentation of a negative tuberculosis screening in their record.
2. Staff #1, Director, confirmed that there was no documentation of a negative tuberculosis screening for Staff #5?s record and was present at the center during the inspection.
Evidence:
1. Staff #5 that started working with children in February 2024, did not have documentation of a negative tuberculosis screening in their record.
2. Staff #1, Director, confirmed that there was no documentation of a negative tuberculosis screening for Staff #5?s record and was present at the center during the inspection.
Plan of Correction: the necessary paperwork was sent to the inspector. The director and ad min have agreed to delegate the children and staff files to each other to prevent this from happening again.
Standard 8VAC20-780-270-A
REPEAT VIOLATION
Based on observation and interview, it was determined that the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a safe and operable condition. Repeat violation.
Evidence:
1. The following are tripping hazards.
a. Television cords in the toddler room on the ground within reach of children in care.
b. The bottom of the entrance door to the daycare center has a torn baseboard panel.
c. The classroom also has carpet lifting off the ground exposing the flooring under the carpet.
2. The following is a strangulation hazard.
a. Television cords in the infant room are hanging off the wall within reach of the children in care.
3. The following are pinching hazards.
a. The bottom of the entrance door to the daycare center has a torn baseboard panel.
b. In the toddler, 2 year old, 3 year old and preschool classrooms, the wood baseboards throughout the classrooms are loose and coming off the main wall.
4. The following are tipping hazards.
a. There is a wooden toy bin structure in the toddler room that is loose and unstable.
b. The plastic playground structure in which children were observed climbing had pieces of the structure falling off and not stable and secure.
c. In the playground, there is a large unstable cylinder block that is leaning against the chain linked fence and placed on top of a plastic preschool basketball hoop.
5. The following are splintering hazards.
a. In the children?s bathroom, the left side of the frame of the door has a hole with wood shavings coming out within reach of children.
b. In the playground area, there was a wooden ping pong paddle that was split in half with wood pieces protruding out of the handle.
7. The following pose an injury hazard.
a. The brick stage area of the daycare center has a sharp edge at the height of children in care.
b. The large commode of the children?s bathroom has a rusted one-inch screw sticking out of the side of the commode. Directly beside the commode is a small training potty chair.
Based on observation and interview, it was determined that the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a safe and operable condition. Repeat violation.
Evidence:
1. The following are tripping hazards.
a. Television cords in the toddler room on the ground within reach of children in care.
b. The bottom of the entrance door to the daycare center has a torn baseboard panel.
c. The classroom also has carpet lifting off the ground exposing the flooring under the carpet.
2. The following is a strangulation hazard.
a. Television cords in the infant room are hanging off the wall within reach of the children in care.
3. The following are pinching hazards.
a. The bottom of the entrance door to the daycare center has a torn baseboard panel.
b. In the toddler, 2 year old, 3 year old and preschool classrooms, the wood baseboards throughout the classrooms are loose and coming off the main wall.
4. The following are tipping hazards.
a. There is a wooden toy bin structure in the toddler room that is loose and unstable.
b. The plastic playground structure in which children were observed climbing had pieces of the structure falling off and not stable and secure.
c. In the playground, there is a large unstable cylinder block that is leaning against the chain linked fence and placed on top of a plastic preschool basketball hoop.
5. The following are splintering hazards.
a. In the children?s bathroom, the left side of the frame of the door has a hole with wood shavings coming out within reach of children.
b. In the playground area, there was a wooden ping pong paddle that was split in half with wood pieces protruding out of the handle.
7. The following pose an injury hazard.
a. The brick stage area of the daycare center has a sharp edge at the height of children in care.
b. The large commode of the children?s bathroom has a rusted one-inch screw sticking out of the side of the commode. Directly beside the commode is a small training potty chair.
Plan of Correction: ? A daily assessment will be done by each teacher and staff in care of their classrooms. The floater will assess the kitchen, bathrooms, hallways, entrance, storage rooms and playground areas. Administrator will do an inspection of the entire building twice a month to identify potential issues, assess risks and plan corrective action plans in a timely fashion.
Standard 8VAC20-780-280-B
REPEAT VIOLATION
Based on observation and interview, it was determined that the center did not ensure that hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children.
Evidence:
1. Upon walking into the center, there was an open storage bin with an air freshener with the warning label, ?Keep out of reach of children? and was within reach and accessible to children in care.
2. In the 3 year old classroom, there was a can of disinfectant wipes and a bottle of disinfectant, with the warning label ?Keep out of reach of children? unlocked and accessible to children in the classroom.
3. In the children?s bathroom, there was an unlocked disinfectant spray bottle with the warning label, ?Keep out of reach of children.?
4. Staff #1, Director, confirmed the air freshener and disinfectant spray bottle was unlocked.
Based on observation and interview, it was determined that the center did not ensure that hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children.
Evidence:
1. Upon walking into the center, there was an open storage bin with an air freshener with the warning label, ?Keep out of reach of children? and was within reach and accessible to children in care.
2. In the 3 year old classroom, there was a can of disinfectant wipes and a bottle of disinfectant, with the warning label ?Keep out of reach of children? unlocked and accessible to children in the classroom.
3. In the children?s bathroom, there was an unlocked disinfectant spray bottle with the warning label, ?Keep out of reach of children.?
4. Staff #1, Director, confirmed the air freshener and disinfectant spray bottle was unlocked.
Plan of Correction: ? The center has bought and implemented child restraining tools. Every member of staff has been informed to keep hazardous materials out of the reach of children, if not, that will result in a write-up that can possibly lead to termination. Administrator will do a walk through after breakfast and a morning snack (as well as making an announcement) while Director will do a walk through after lunch and pm snack (as well as making announcements).
Standard 8VAC20-780-330-B
Based on observation and interview, it was determined the center failed to ensure that where playground equipment is provided, resilient surfacing shall comply with minimum safety standards when tested in accordance with the procedures described in the American Society for Testing and Materials standard F1292-99 and shall be under equipment with moving parts or climbing apparatus to create a fall zone free of hazardous obstacles.
Evidence:
1. In the playground area, the children were observed coming off the slide and landing on grass and dirt.
2. Several staff member confirmed there is no resilient surfacing to each play structure with slides and that they children are landing on grass and dirt.
3. Staff #2, administrator, confirmed that there is no resilient surfacing to each play structure.
Evidence:
1. In the playground area, the children were observed coming off the slide and landing on grass and dirt.
2. Several staff member confirmed there is no resilient surfacing to each play structure with slides and that they children are landing on grass and dirt.
3. Staff #2, administrator, confirmed that there is no resilient surfacing to each play structure.
Plan of Correction: ? The director will ensure to keep the original plans of taking toys, items to the play area daily and if the center decide to incorporate slides etc. they will follow the standards to ensure that resilient surfacing is implemented.
Standard 8VAC20-780-340-F
Based on observation and interview, it was determined that the center did not ensure that children under 10 years of age were within actual sight and sound supervision of staff.
Evidence:
1. While inspecting the children?s restroom area, inspectors observed a 3 year old child walk to the bathroom without adult supervision. The restroom was outside of the classroom approximately more than 6ft away down a hallway. Inspectors walked the child back to their classroom and asked the teacher if they were aware of the child leaving the classroom.
a. No adults were in the bathroom while child entered.
b. The teacher gave confirmation that they were unaware that the child had left the classroom and walked to the bathroom alone.
2. The teacher in the 2 year old classroom left a child alone in the classroom while gathering the children to wash their hands in the bathroom down the hall.
a. Staff #2, observed a child left alone in the 2 year old classroom while the rest of the students were washing their hands in the bathroom area located outside of the classroom.
3. In the infant room, the diaper disposal storage unit was outside of the classroom. An infant teacher was observed leaving the classroom to dispose of a diaper. Five infant children were left in the classroom unattended.
4. Upon walking into the 4 year old classroom, there were six children observed sitting at the table with no teacher in the room.
a. The teacher was observed walking a child back from the restroom.
Evidence:
1. While inspecting the children?s restroom area, inspectors observed a 3 year old child walk to the bathroom without adult supervision. The restroom was outside of the classroom approximately more than 6ft away down a hallway. Inspectors walked the child back to their classroom and asked the teacher if they were aware of the child leaving the classroom.
a. No adults were in the bathroom while child entered.
b. The teacher gave confirmation that they were unaware that the child had left the classroom and walked to the bathroom alone.
2. The teacher in the 2 year old classroom left a child alone in the classroom while gathering the children to wash their hands in the bathroom down the hall.
a. Staff #2, observed a child left alone in the 2 year old classroom while the rest of the students were washing their hands in the bathroom area located outside of the classroom.
3. In the infant room, the diaper disposal storage unit was outside of the classroom. An infant teacher was observed leaving the classroom to dispose of a diaper. Five infant children were left in the classroom unattended.
4. Upon walking into the 4 year old classroom, there were six children observed sitting at the table with no teacher in the room.
a. The teacher was observed walking a child back from the restroom.
Plan of Correction: ? Every member of staff has been retrained and given the standards on sight and sound supervision throughout the center. Each teacher must assist their class to the bathroom area and must remain with them for the duration of time. If the staff is not able to go to the restroom with a child, the teacher will request for assistance using the walkie talkie.
Standard 8VAC20-780-350-B-1
Based on observation and interview, it was determined that the center did not ensure that the ratio for children birth up to 16 months was 1:4 (one staff to four children.)
Evidence:
1. There were five infant children under the age of 13 months that were in the classroom with one staff member.
2. Staff #1, Director, confirmed that there was one staff member supervising five infant children.
Evidence:
1. There were five infant children under the age of 13 months that were in the classroom with one staff member.
2. Staff #1, Director, confirmed that there was one staff member supervising five infant children.
Plan of Correction: Director had a meeting and discussed every teacher?s child to ratio standard. Each member of staff must stay in compliance of ratio daily by taking attendance and informing the director if the numbers are out of compliance. The director will be sure to keep the class enrollment to the standards as well as hiring more staff to stay within compliance.
Standard 8VAC20-780-440-B
REPEAT VIOLATION
Based on observation and interview, it was determined that the center did not ensure that cribs, be identified for use by a specific child. Repeat violation.
Evidence:
1. In the infant room, there were two infant children observed in cribs with name labels of a different child.
a. Infant staff and director confirmed that two infant children were in cribs with name labels of a different child.
Based on observation and interview, it was determined that the center did not ensure that cribs, be identified for use by a specific child. Repeat violation.
Evidence:
1. In the infant room, there were two infant children observed in cribs with name labels of a different child.
a. Infant staff and director confirmed that two infant children were in cribs with name labels of a different child.
Plan of Correction: The staff was reprimanded and has agreed to follow standards at all times.
Standard 8VAC20-780-440-E
Based on observation and interview, it was determined that the center did not ensure that there was at least 12 inches of space between occupied cots, beds, and rest mats.
Evidence:
1. In the infant room, there were two occupied cribs that were 6 inches apart.
2. Infant teacher and director confirmed that there was not at least 12 inches of space between the two occupied cribs.
Evidence:
1. In the infant room, there were two occupied cribs that were 6 inches apart.
2. Infant teacher and director confirmed that there was not at least 12 inches of space between the two occupied cribs.
Plan of Correction: This violation was corrected upon inspection. The
teacher is aware of the space that's needed and will comply with standards.
teacher is aware of the space that's needed and will comply with standards.
Standard 8VAC20-780-550-P
REPEAT VIOLATION
Based on record review and interview, it was determined that the center did not ensure that they maintained a written record of children's serious and minor injuries in which entries with all required elements.
Evidence:
1. 2 of the 5 injury reports reviewed did not have the required documentation entries in the report.
a. Injury report #1 dated 12/21/23, did not list the staff present and did not have the date and time parents were notified of the injury.
b. Injury report #2 dated 2/8/24, did not list the time of injury, staff present, and date parents were notified.
2. Staff #1 and Staff #2 confirmed that both injury reports were missing documentation entries in the reports.
Based on record review and interview, it was determined that the center did not ensure that they maintained a written record of children's serious and minor injuries in which entries with all required elements.
Evidence:
1. 2 of the 5 injury reports reviewed did not have the required documentation entries in the report.
a. Injury report #1 dated 12/21/23, did not list the staff present and did not have the date and time parents were notified of the injury.
b. Injury report #2 dated 2/8/24, did not list the time of injury, staff present, and date parents were notified.
2. Staff #1 and Staff #2 confirmed that both injury reports were missing documentation entries in the reports.
Plan of Correction: Training was done with all the staff to ensure we are in compliance with every injury report and gave knowledge on how to properly fill one out.
Standard 8VAC20-780-60-A
REPEAT VIOLATION
Based on record review and interview, it was determined that the center did not ensure that each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the work phone number each parent who has custody. Repeat violation.
Evidence:
1. Child #1 (date of enrollment 8/03/2023) did not have a work phone number listed for their parent.
2. Child #2 (date of enrollment 4/24/2023) did not have a work phone number listed for both parents.
3. Staff #1 confirmed that there are no work phone numbers listed for Child #1 and Child #2 in their record.
Based on record review and interview, it was determined that the center did not ensure that each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the work phone number each parent who has custody. Repeat violation.
Evidence:
1. Child #1 (date of enrollment 8/03/2023) did not have a work phone number listed for their parent.
2. Child #2 (date of enrollment 4/24/2023) did not have a work phone number listed for both parents.
3. Staff #1 confirmed that there are no work phone numbers listed for Child #1 and Child #2 in their record.
Plan of Correction: The director and admin have agreed to delegate the children and staff files to each other to prevent this from happening again in the future
Standard 8VAC20-780-70
REPEAT VIOLATION
Based on record review and interview, it was determined that the center did not ensure that staff records shall be kept for each staff person to include documentation that two or more references as to character and reputation as well as competency were checked before employment. If a reference check is taken over the phone, documentation shall include: a. Dates of contact; b. Names of persons contacted; c. The firms contacted; d. Results; and e. Signature of person making call. Repeat violation.
Evidence:
1. Three of the four staff records reviewed did not have completed documentation of two reference checks taken over the phone.
a. Staff #3 did not have documentation that two or more references as to character and reputation as well as competency were checked before employment.
b. Staff #4 did not have the results, date of contact and the signature of the person making the reference call in her record.
c. Staff #5 did not have documentation that two or more references as to character and reputation as well as competency were checked before employment.
Based on record review and interview, it was determined that the center did not ensure that staff records shall be kept for each staff person to include documentation that two or more references as to character and reputation as well as competency were checked before employment. If a reference check is taken over the phone, documentation shall include: a. Dates of contact; b. Names of persons contacted; c. The firms contacted; d. Results; and e. Signature of person making call. Repeat violation.
Evidence:
1. Three of the four staff records reviewed did not have completed documentation of two reference checks taken over the phone.
a. Staff #3 did not have documentation that two or more references as to character and reputation as well as competency were checked before employment.
b. Staff #4 did not have the results, date of contact and the signature of the person making the reference call in her record.
c. Staff #5 did not have documentation that two or more references as to character and reputation as well as competency were checked before employment.
Plan of Correction: ? The Director will ensure that each staff have an employment application (name, address, verification of age , job title date of employment, and name/address of a person to be notified in an emergency which will be kept here at the center) , two references, background checks, documentation to ensure that they possesses the education certificate and experience needed, first aid and cpr, health information and any health problems and date of separation in there staff records. Each staff record will be checked annually.