Inspection · 2023-04-12
Date
2023-04-12
Complaint Related
No
Licensing Inspector
Kristy Atanackovic
(804) 629-5032
(804) 629-5032
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
Inspector Notes
An unannounced renewal inspection was conducted on 4/12/2023 from 10:45 am-3:30 pm. There were 93 children supervised by 12 direct care staff. The physical plant, 6 staff records, 5 children?s records, medications, evacuation drills, injury reports, emergency supplies, and policies were inspected. Children were observed participating in group play, playing outside, and eating lunch. Areas of non-compliance are identified in the Violation Notice. Thank you for your cooperation during this inspection. If you have any questions regarding this inspection, contact kristy.atanackovic@doe.virginia.gov
Violations
10Standard 22.1-289.035-A
Based on record review and interview, it was determined that not all background checks were repeated every five years.
Evidence:
1. The most recent sworn statement on file for Staff #3 is dated 9/21/2017.
Evidence:
1. The most recent sworn statement on file for Staff #3 is dated 9/21/2017.
Plan of Correction: update sworn statements.
Standard 8VAC20-770-60-B
Based on record review and interview, a sworn statement was not completed prior to first day of employment.
Evidence: There was no documentation of a sworn statement for staff #5 (DOH: 11/14/2022).
Evidence: There was no documentation of a sworn statement for staff #5 (DOH: 11/14/2022).
Plan of Correction: Check started file for sworn statement.
Standard 8VAC20-770-60-C-2
Based on record review and interview, the center did not obtain the results of a central registry check by end of the 30th day of employment.
Evidence: There was no documentation of central registry results for staff #1 (DOH: 12/27/2021), staff #3 (DOH: 11/14/2004) staff #4 (DOH: 6/15/2022), staff #5 (DOH: 11/14/2022), and staff #6 (DOH: 3/16/2022).
Evidence: There was no documentation of central registry results for staff #1 (DOH: 12/27/2021), staff #3 (DOH: 11/14/2004) staff #4 (DOH: 6/15/2022), staff #5 (DOH: 11/14/2022), and staff #6 (DOH: 3/16/2022).
Plan of Correction: Will follow up every 30 days if the registry is not received.
Standard 8VAC20-780-160-A
Based on a record review and interview, two of five staff records did not contain documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Evidence: The record for staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not contain documentation of a negative tuberculosis screening.
Evidence: The record for staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not contain documentation of a negative tuberculosis screening.
Plan of Correction: TB Test screening prior to coming in contact with children.
Standard 8VAC20-780-245-J-3
Based on record review and interview, the center failed to ensure that a staff person was onsite with MAT training when emergency medication was present.
Evidence: Staff #1's MAT (medication administration training) certification expired on 3/6/2023. During the inspection, there was no documentation of another staff member on site with current MAT certification. There were two emergency medications on-site during the inspection.
Evidence: Staff #1's MAT (medication administration training) certification expired on 3/6/2023. During the inspection, there was no documentation of another staff member on site with current MAT certification. There were two emergency medications on-site during the inspection.
Plan of Correction: We were able to get training certificate from MAT trainer.
Standard 8VAC20-780-270-A
Based on observation, areas and equipment of the center, inside and outside were not maintained in a clean, safe and operable condition.
Evidence:
1. The gate used as a barrier between the infant and toddler classroom had several areas of peeling paint around its frame.
2. In the outdoor breezeway of the infant and two's classrooms, a medium-sized unanchored bookcase was leaning against a wall.
Evidence:
1. The gate used as a barrier between the infant and toddler classroom had several areas of peeling paint around its frame.
2. In the outdoor breezeway of the infant and two's classrooms, a medium-sized unanchored bookcase was leaning against a wall.
Plan of Correction: Have gate painted and remove bookcase from walkway.
Standard 8VAC20-780-280-B
Based on observation and interview, hazardous substances such as cleaning materials, insecticides, and pesticides were not kept in a locked place using a safe locking method that prevents access by children.
Evidence: In the Infant room, spray bottles of sanitizer, disintectant, and glass cleaner were kept in an unlocked cabinet under the diaper changing table.
Evidence: In the Infant room, spray bottles of sanitizer, disintectant, and glass cleaner were kept in an unlocked cabinet under the diaper changing table.
Plan of Correction: Moved spray bottles to a locked cabinet.
Standard 8VAC20-780-550-H
Based on review of the emergency drill log, the facility did not maintain a record of the dates of the monthly practiced evacuation drills for one year.
Evidence: There was no documentation of a practiced emergency evacuation drill for August 2022 through December 2022.
Evidence: There was no documentation of a practiced emergency evacuation drill for August 2022 through December 2022.
Plan of Correction: Will not store evacuation drills until after a year.
Standard 8VAC20-780-60-A
Based on record review, the center did not obtain all the required information for each child's record.
Evidence: Child #5 is missing proof of identity.
Evidence: Child #5 is missing proof of identity.
Plan of Correction: Will collect all required information.
Standard 8VAC20-780-70
Based on record review and interview, staff records were missing two references.
Evidence: Staff #1 (DOH: 12/27/2021), staff #2 (DOH: 12/19/2022), and staff #3 (DOH: 11/14/2004) records were missing documentation that two or more references as to character and reputation as well as competency were checked before employment.
Evidence: Staff #1 (DOH: 12/27/2021), staff #2 (DOH: 12/19/2022), and staff #3 (DOH: 11/14/2004) records were missing documentation that two or more references as to character and reputation as well as competency were checked before employment.
Plan of Correction: Will collect required information.