Inspection · 2023-07-18
Date
2023-07-18
Complaint Related
Yes
Licensing Inspector
Beth Orebaugh
(540) 847-9173
(540) 847-9173
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
Inspector Notes
An unannounced complaint inspection was conducted on 07/18/2023 from 2:00 p.m. to 5:00 p.m. The complaint was received on 07/14/2023 regarding administration, physical plant, staffing and supervision, programs, special care provisions and emergencies and special services.
Information gathered during the inspection supports at least one of the allegations and the complaint was determined to be valid. Two complaint related violations and one non-complaint violation were documented on the violation notice issued to the program.
If you have any questions or concerns, please contact the Licensing Inspector at (804) 629-3923.
Violations
3Standard 8VAC20-780-200-A
Complaint Related
Based on interviews and review of documentation, the center failed to have a qualified program director or a qualified back-up program director who meets one of the director qualifications who is regularly on site at least 50% of the center's hours of operation.
Evidence:
1. During interview on 07/18/2023, Staff #1 confirmed that Staff #10 is the only program director and that there is not a qualified back-up program director.
2. Staff #10 was not present during the inspection conducted at the center between the hours of 2:00 p.m. and 4:00 p.m. on 07/18/2023.
3. Two of the eight staff members interviewed said the program director is present at the center at least 50% of the center?s operating hours.
4. One of the eight staff members interviewed responded that ?it doesn?t seem like it? when asked if the director is regularly at the center at least 50% of the center?s operating hours.
5. One of the eight staff members interviewed does not work a full-time regular shift and was unsure if Staff #10 is regularly present at least 50% of the center?s operating hours.
6. Four of the eight staff members interviewed stated that the program director is not regularly at the center 50% of the center?s operating hours.
Based on interviews and review of documentation, the center failed to have a qualified program director or a qualified back-up program director who meets one of the director qualifications who is regularly on site at least 50% of the center's hours of operation.
Evidence:
1. During interview on 07/18/2023, Staff #1 confirmed that Staff #10 is the only program director and that there is not a qualified back-up program director.
2. Staff #10 was not present during the inspection conducted at the center between the hours of 2:00 p.m. and 4:00 p.m. on 07/18/2023.
3. Two of the eight staff members interviewed said the program director is present at the center at least 50% of the center?s operating hours.
4. One of the eight staff members interviewed responded that ?it doesn?t seem like it? when asked if the director is regularly at the center at least 50% of the center?s operating hours.
5. One of the eight staff members interviewed does not work a full-time regular shift and was unsure if Staff #10 is regularly present at least 50% of the center?s operating hours.
6. Four of the eight staff members interviewed stated that the program director is not regularly at the center 50% of the center?s operating hours.
Plan of Correction: I am present at the center more than 50% of the center's hours of operation.
Standard 8VAC20-780-340-B
Complaint Related
Based on interviews, the center failed to ensure that during the center?s hours of operation, one adult on the premises shall be in charge of the administration of the center.
Evidence:
1. Eight of the eight staff members interviewed, stated that Staff #10 is in charge of the operation of the center, and in the absence of Staff #10, Staff #1 is in charge of the administration of the center.
2. Eight of the eight staff members interviewed stated that neither Staff #10 nor Staff #1 are at the center after 3:00 p.m. on a regular basis.
3. On 07/18/2023, Staff #10 was not present during the interview and Staff #1 left the center around 3:00 p.m. before the inspection concluded. Out of eight staff members interviewed, when asked who is in charge of administration of the center when Staff #10 and Staff #1 are not at the center: four of eight stated no one is in charge; two of eight stated Staff #4 is in charge (Staff #4 was not aware of being in charge and confirmed leaving the center at 3:00pm); one of eight stated Staff #6 or Staff #7 is in charge; and one of eight stated seniority is what determines who is in charge.
4. During the exit interview on 07/31/2023, Staff #10 confirmed Staff #10 is in charge of the operation of the center, and in the absence of Staff #10, Staff #1 is in charge of the administration of the center. Staff #10 also stated that when Staff #10 and Staff #1 are not at the center, seniority determines who is in charge.
Based on interviews, the center failed to ensure that during the center?s hours of operation, one adult on the premises shall be in charge of the administration of the center.
Evidence:
1. Eight of the eight staff members interviewed, stated that Staff #10 is in charge of the operation of the center, and in the absence of Staff #10, Staff #1 is in charge of the administration of the center.
2. Eight of the eight staff members interviewed stated that neither Staff #10 nor Staff #1 are at the center after 3:00 p.m. on a regular basis.
3. On 07/18/2023, Staff #10 was not present during the interview and Staff #1 left the center around 3:00 p.m. before the inspection concluded. Out of eight staff members interviewed, when asked who is in charge of administration of the center when Staff #10 and Staff #1 are not at the center: four of eight stated no one is in charge; two of eight stated Staff #4 is in charge (Staff #4 was not aware of being in charge and confirmed leaving the center at 3:00pm); one of eight stated Staff #6 or Staff #7 is in charge; and one of eight stated seniority is what determines who is in charge.
4. During the exit interview on 07/31/2023, Staff #10 confirmed Staff #10 is in charge of the operation of the center, and in the absence of Staff #10, Staff #1 is in charge of the administration of the center. Staff #10 also stated that when Staff #10 and Staff #1 are not at the center, seniority determines who is in charge.
Plan of Correction: We posted the chain of command in the entryway of the center and reminded all staff personnel of who was in charge once the director left for the day so there was never confusion of who was in charge in the absence of the center director. If the director is out it goes by seniority of who has been at the center the longest if the office administrator is absent.
Standard 8VAC20-780-340-F
Based on interview and observation, the center failed to ensure that children under the age of 10 years old are within actual sight and sound supervision of staff.
Evidence:
1. On 07/18/2023, Staff #5 was observed leaving the older 3?s classroom to open the front door for a parent.
2. Staff #5 confirmed that they had left the classroom to open the front door, leaving the children in the older 3?s classroom (all three years of age) alone and out of sight and sound supervision of staff.
Evidence:
1. On 07/18/2023, Staff #5 was observed leaving the older 3?s classroom to open the front door for a parent.
2. Staff #5 confirmed that they had left the classroom to open the front door, leaving the children in the older 3?s classroom (all three years of age) alone and out of sight and sound supervision of staff.
Plan of Correction: We no longer leave the front door unlocked resulting in it being shut and locked at all times for parents and center staff alike. Teachers have ALL been told to NEVER leave the classroom when they are needed in ratio to open the door for anyone. If there is an extra staff member in the building they are to open the door as needed or the director at the desk will always open the door whenever someone is there so teachers NEVER leave their students unattended.