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Making A Difference Step By Step LLC

Inspection · 2024-11-06

Date
2024-11-06
Complaint Related
No
Licensing Inspector
Arlene Agustin
(804) 629-7519
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

During the inspection, the inspector reviewed the areas listed above.

Inspector Notes

An unannounced, on-site renewal inspection was initiated and completed on 11/06/2024, as a part of the licensure period. The inspection began at 10:15 AM and ended at 12:25 PM. The inspector reviewed compliance in the areas listed above. There were 19 children present and 7 staff. The inspector reviewed 3 children?s records and 5 staff records on site. This inspection included:
- document review,
- tour of the facility,
- interviews, and
- observations.

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.

Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on November 13, 2024. A POC submitted after this date will not appear on the public website.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.

Violations

5
Standard 8VAC20-780-240-B
Staff shall complete orientation training prior to the staff member working alone with child and no later than seven days of the date of assuming job responsibilities.

Staff 1, employed 15 days, and staff 2 employed 14 days, have not completed orientation training.
Staff 3, employed 3 months, has no documentation of completing orientation training.
Staff 4 did not complete orientation training until employed 11 days of assuming job responsibilities.
Staff 5, employed 9 days, has not completed orientation training
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-G
Documentation shall be maintained of emergency evacuation, shelter-in-place, and lockdown drills shall include all required documentation..
The center's documentation of emergency drills did not include documentation of the person conducting the drill, the method used for notification of the drill and for evacuation drills, the weather conditions.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the previous and concurrent programs the child has/is attending.

The records for child 1, child 2 and child 3 did not contain documentation of any previous programs attended or any programs concurrently attending.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-70
Staff records shall be kept for each staff person that includes documentation that two or more references as to character and reputation as well as competency were checked before employment.

The records for staff 3 and staff 5 contained only one documented reference.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-90-A
the record for each enrolled child shall contain a written agreement between the parent and the center by the child's first day of attendance that the parent will inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed any reportable communicable disease, as defined by the State Board of health, except for life threatening diseases which must be reported immediately.

The records for child 1, child 2 and child 3 did not contain the required written parent's agreement.
Plan of Correction: Not available online. Contact Inspector for more information.