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Lynchburg Community Action Group, Inc. - Big Island

Inspection · 2025-05-07

Date
2025-05-07
Complaint Related
No
Licensing Inspector
Shanae Vaughn
(276) 608-4267
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
20 Access to minor?s record
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect

During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.

Inspector Notes

An unannounced, on-site monitoring inspection was initiated and completed on 05/07/2025. The on-site inspection began at 9:00 a.m. and ended at 10:10 a.m. The inspector reviewed compliance in the areas listed above. There were 14 children present and 2 staff. The inspector reviewed 5 children?s records on-site and 2 staff records at the admin office 05/07/2025. This inspection included document review, tour of the facility, interviews, observations, and measurements.

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.

Violations

3
Standard 8VAC20-780-260-B
Annual approval from the health department shall be provided.

The annual health inspection was overdue by 8 months.
Plan of Correction: Admin will contact the health department.
Standard 8VAC20-780-40-E
The operational responsibilities of the license shall include ensuring that the activities, services and facilities are maintained in compliance with the center?s own policies and procedures.

The center?s medication policy states that ?when a medication or authorization for medication expires, the parents will be notified that the medication must be picked up within 14 days or it will be disposed of by the center?. Medication 1 expired 8/2024 and was at the center during the inspection.
Plan of Correction: Staff will follow policy.
Standard 8VAC20-780-520-A
Nonprescription drugs and over-the-counter skin products shall not be kept or used beyond the expiration date of the product.

Medication 1 was used over 2 months beyond the expiration date.
Plan of Correction: Medication will be returned to parent.
View original record on Virginia Department of Social Services