Inspection · 2024-09-09
Date
2024-09-09
Complaint Related
No
Licensing Inspector
Anita Drewry
(757) 404-5261
(757) 404-5261
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.
8VAC20-770 BACKGROUND CHECKS
8VAC20-820 THE LICENSE.
22.1 BACKGROUND CHECKS CODE; CARBON MONOXIDE
Inspector Notes
An unannounced, on-site monitoring inspection was initiated and completed on September 9, 2024, as a part of the licensure period. The on-site inspection began at 1:30 pm and ended at 4:05 pm. The inspector reviewed compliance in the areas listed above. There were 11 children present and 4 staff. The inspector reviewed 5 children?s records and 4 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 September 19, 2024. A POC submitted after this date will not appear on the public website.
Violations
12Standard 22.1-289.035-A
Based on review, facility did not ensure required background checks are updated every 5 years.
Evidence: The record for staff #4 had most recent fingerprinting letter and central registry search dated 2018 which is beyond 5 years old. Missing information was confirmed by director.
Evidence: The record for staff #4 had most recent fingerprinting letter and central registry search dated 2018 which is beyond 5 years old. Missing information was confirmed by director.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-B-2
Based on review, facility did not ensure 1 of 5 staff have a completed fingerprinting letter of eligibility prior to beginning employment.
Evidence: The record for staff #1 (start date 4/21/2024) did not have a fingerprinting letter of eligibility. Missing information was confirmed by director.
Evidence: The record for staff #1 (start date 4/21/2024) did not have a fingerprinting letter of eligibility. Missing information was confirmed by director.
Plan of Correction: All staff will have appropriate documentation provided and filed by Director before 10/01/2024
Standard 8VAC20-770-60-C-2
Based on review, facility did not ensure 1 of 5 staff have a completed central registry search.
Evidence: The record for staff #1 (start date 4/24/2024) did not have a completed central registry search. Missing information was confirmed by director.
Evidence: The record for staff #1 (start date 4/24/2024) did not have a completed central registry search. Missing information was confirmed by director.
Plan of Correction: All staff will have a central registry check, including the director. Central registry checks completed on 9/9/2024 for all staff in the online portal.
Standard 8VAC20-780-150-A
Based on review, facility did not ensure 2 of 5 child record physical examinations are signed by a physician, designee or health department official.
Evidence: The records for child #1 and child #2 had physicals that were not signed.
Evidence: The records for child #1 and child #2 had physicals that were not signed.
Plan of Correction: All student documentation will be required to be signed by physician and resubmitted to the center.
Standard 8VAC20-780-150-B
Based on review, facility did not ensure 1 of 5 child record immunizations are signed by a physician, designee or health department official.
Evidence: The record for child #2 had an immunization record that was not signed.
Evidence: The record for child #2 had an immunization record that was not signed.
Plan of Correction: All student documentation will be required to be signed by physician and resubmitted to the center.
Standard 8VAC20-780-240-A
Based on review, facility did not ensure 2 of 5 staff complete the Virginia Department of Education (VDOE)-sponsored orientation course within 90 calendar days of employment.
Evidence: The record for staff #1 (start date 4/21/2024) and staff #3 (start date 6/24/2023) did not have documentation of completing the VDOE-sponsored orientation course. Staff confirmed the training has not been done.
Evidence: The record for staff #1 (start date 4/21/2024) and staff #3 (start date 6/24/2023) did not have documentation of completing the VDOE-sponsored orientation course. Staff confirmed the training has not been done.
Plan of Correction: All staff will have VDOE Sponsored orientation course completed within 90 days of hire.
Standard 8VAC20-780-330-B
Based on observation, facility did not ensure where playground equipment is provided, resilient surfacing shall comply with the minimum safety standards in accordance with the American Society for Testing and Materials (ASTM). There shall be sufficient resilient surfacing in the fall zones under and around equipment with climbing and/or moving parts.
Evidence: There is not sufficient fall zones and resilient surfacing under and around the two composite pieces of play equipment on the outside playground. The pieces have slides and swings. The borders are within fall zones and grass has grown to impair the surfacing. One piece of composite equipment with a red circular slide is labeled for use by children ages 9-12 years.
Evidence: There is not sufficient fall zones and resilient surfacing under and around the two composite pieces of play equipment on the outside playground. The pieces have slides and swings. The borders are within fall zones and grass has grown to impair the surfacing. One piece of composite equipment with a red circular slide is labeled for use by children ages 9-12 years.
Plan of Correction: Playground will not be in use by MSLC and equipment will be removed from the grounds. We will ensure that there is a play area conducive to learning and safe play for ages 2-5.
Standard 8VAC20-780-540-E
Based on observation, facility did not ensure the required nonmedical emergency supplies are available.
Evidence: The radio was not operable with batteries.
Evidence: The radio was not operable with batteries.
Plan of Correction: All required non medical emergency supplies will be in the facility.
Standard 8VAC20-780-550-G
Based on review, facility did not ensure there is documentation of emergency evacuation drills.
Evidence: There was not documentation of evacuation drills conducted in June and August 2024.
Evidence: There was not documentation of evacuation drills conducted in June and August 2024.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-60-A
Based on review, facility did not ensure 5 of 5 child records have documentation of required information.
Evidence: The following was found during record review:
1. The record for child #1 (start date 9/6/2023) did not have an immunization record.
2. The record for child #2 did not have documentation of start date and parent employment phone numbers.
3. The record for child #3 (start date 10/3/2023) did not have parent employment phones numbers and emergency contact addresses.
4. The record for child #4 (start date 11/13/2023) did not have 2nd emergency contact address, physical examination and immunization record.
5. The record for child #5 (start date 4/17/2023) did not have one parent's home address, phone number and employment information.
6. Missing information was confirmed by director.
Evidence: The following was found during record review:
1. The record for child #1 (start date 9/6/2023) did not have an immunization record.
2. The record for child #2 did not have documentation of start date and parent employment phone numbers.
3. The record for child #3 (start date 10/3/2023) did not have parent employment phones numbers and emergency contact addresses.
4. The record for child #4 (start date 11/13/2023) did not have 2nd emergency contact address, physical examination and immunization record.
5. The record for child #5 (start date 4/17/2023) did not have one parent's home address, phone number and employment information.
6. Missing information was confirmed by director.
Plan of Correction: Children?s records had information in their files; however, the records will also have PCP signatures. All information will be gathered for all students.
Standard 8VAC20-780-70
Based on interview, facility did not ensure 1 of 5 staff have a record with required information.
Evidence: The record for staff #2 was not available for review. Director reported she could not locate the file.
Evidence: The record for staff #2 was not available for review. Director reported she could not locate the file.
Plan of Correction: All staff information will be on site.
Standard 8VAC20-780-80-A
Based on observation and review, facility did not ensure for each group of children there is written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
Evidence: The attendance noted electronically showed 12 children present however 11 children were observed in the group. Director confirmed the attendance was not accurate at that time.
Evidence: The attendance noted electronically showed 12 children present however 11 children were observed in the group. Director confirmed the attendance was not accurate at that time.
Plan of Correction: Attendance will reflect children in an appropriate group, and at the current time.