Inspection · 2024-09-12
Date
2024-09-12
Complaint Related
No
Licensing Inspector
Stacy Doyle
(571) 835-0386
(571) 835-0386
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.
8VAC20-770 Background Checks
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
An unannounced, on-site monitoring inspection was initiated and completed on 9/12/2024. The on-site inspection began at 9:21am and ended at 12:30pm. The inspector reviewed compliance in the areas listed above. There were (44) children present and (10) staff. The inspector reviewed (4) children?s records and (5) staff records [on-site] on 9/12/2024. This inspection included document review, emergency drill logs, tour of the facility 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 (9/19/2024). A POC submitted after this date will not appear on the public website.
Violations
14Standard 22.1-289.035-B-1
Based on review of staff records, the center did not have a completed sworn disclosure
statement for each staff prior to date of hire.
Evidence:
1. Staff #5 (Date of hire 4/29/2024) did not have a sworn disclosure form on file for this entity. The center had the form for the staff person signed 1/22/2023 for a different entity/location.
statement for each staff prior to date of hire.
Evidence:
1. Staff #5 (Date of hire 4/29/2024) did not have a sworn disclosure form on file for this entity. The center had the form for the staff person signed 1/22/2023 for a different entity/location.
Plan of Correction: Staff 5 will complete a new sworn disclosure for the current entity.
Standard 22.1-289.035-B-2
Repeat Violation
Based on record review, two staff members did not have the fingerprint results prior to hire.
Evidence:
1. Staff #4 (Date of hire 8/13/2024) had fingerprint results dated 9/03/2024 and were
received after the hire date.
2. Staff #5 (Date of hire 4/29/2024) had fingerprint results dated 1/20/2023 for a different Entity and did not have results for this location/entity..
Based on record review, two staff members did not have the fingerprint results prior to hire.
Evidence:
1. Staff #4 (Date of hire 8/13/2024) had fingerprint results dated 9/03/2024 and were
received after the hire date.
2. Staff #5 (Date of hire 4/29/2024) had fingerprint results dated 1/20/2023 for a different Entity and did not have results for this location/entity..
Plan of Correction: Staff 4 has fingerprints for both 301030 A & B. Employee did not start in B until fingerprints were done. Staff 5 will obtain new fingerprints for the current entity.
Standard 22.1-289.035-B-3
Based on record review, the center did not obtain a copy of the results of a search of the
central registry within 30 days of employment.
Evidence:
1. Staff #5 (Date of hire 4/29/2024) had central registry results dated 1/30/2023 for a
different location with a different Entity and did not have results for this location/Entity..
central registry within 30 days of employment.
Evidence:
1. Staff #5 (Date of hire 4/29/2024) had central registry results dated 1/30/2023 for a
different location with a different Entity and did not have results for this location/Entity..
Plan of Correction: Staff 5 will provide new central registry search
Standard 22.1-289.035-B-4
Based on record review, the center did not request a copy of the results of the sex offender registry check and search of the child abuse and neglect registry from any state in which the individual had resided in the preceding five years prior to hire.
Evidence:
1. Staff #2 (Date of hire 8/30/2024) began at the center and the center had not requested the Sex Offender registry results or the Child Abuse and Neglect Results from MD prior to hire.
2. Staff #4 (Date of hire 8/13/204) began at the center and the center had not requested the Sex Offender registry results or the Child Abuse and Neglect Results from WV prior to hire..
Evidence:
1. Staff #2 (Date of hire 8/30/2024) began at the center and the center had not requested the Sex Offender registry results or the Child Abuse and Neglect Results from MD prior to hire.
2. Staff #4 (Date of hire 8/13/204) began at the center and the center had not requested the Sex Offender registry results or the Child Abuse and Neglect Results from WV prior to hire..
Plan of Correction: Center will complete all background checks prior to hire date-both cps and sex offender registry
CPS corrected and sent 9/13/2024 Sex Offender Registry corrected and completed 9/12/2024.
CPS corrected and sent 9/13/2024 Sex Offender Registry corrected and completed 9/12/2024.
Standard 8VAC20-780-160-A
Based on review, the center did not obtain documentation of a negative tuberculosis
screening at the time of employment and must be completed within the last 30 days of hire.
Evidence:
1. Staff #5 (Date of hire 4/29/2024) did not have a TB test or screening on file for this entity/location. The center had a TB test or screening dated 1/22/2023 for a different Entity.
2. Staff #1, Staff #2 and Staff #3 all began employment 8/30/2024 and the center received the results on 8/31/2024 for all 3 staff.
screening at the time of employment and must be completed within the last 30 days of hire.
Evidence:
1. Staff #5 (Date of hire 4/29/2024) did not have a TB test or screening on file for this entity/location. The center had a TB test or screening dated 1/22/2023 for a different Entity.
2. Staff #1, Staff #2 and Staff #3 all began employment 8/30/2024 and the center received the results on 8/31/2024 for all 3 staff.
Plan of Correction: TB test will be conducted prior to the staff person starting at the center
Standard 8VAC20-780-240-B
Based on record review, the staff did not complete orientation training in subsection C of this section prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
Evidence:
1. Staff #5 (Date of hire 4/29/2024) did not complete orientation training for this location/entity.
Evidence:
1. Staff #5 (Date of hire 4/29/2024) did not complete orientation training for this location/entity.
Plan of Correction: Orientation will be completed for 301030 B
Standard 8VAC20-780-270-A
Repeat Violation
Based on observation, areas and equipment of the center, inside were not maintained in a safe and operable condition.
Evidence:
1. In the Two's B classroom, a sink that children use had a large crack near the
faucet approximately 8 inches long. The changing table had approximately 12 areas
that were cracked or breaking off on the edge of the table. The base board is pulling away from the wall near the window.
Based on observation, areas and equipment of the center, inside were not maintained in a safe and operable condition.
Evidence:
1. In the Two's B classroom, a sink that children use had a large crack near the
faucet approximately 8 inches long. The changing table had approximately 12 areas
that were cracked or breaking off on the edge of the table. The base board is pulling away from the wall near the window.
Plan of Correction: work order placed 9/13/2024 -maintenance will replace and repair items by end of month
Standard 8VAC20-780-280-B
Repeat Violation
Based on observation, hazardous substances were not kept in a locked place using a safe
locking method that prevent access by children.
Evidence:
1. In the Discovery Preschool 1 classroom, A Febreze spray was on top of the counter near the sink.
2. In the 2's Classroom B classroom, 3 spray bottles of multi-surface and disinfectant sanitizer were under the sink and not locked. The cabinet slides freely. A Lysol disinfectant spray was in a high level cabinet near the changing table unlocked and had the key in the lock.
3. In the infant classroom, Fabulosa, Sanitizer and air freshener were inside a lower cabinet under the changing table and were not kept locked. The cabinet opens if pushed.
Based on observation, hazardous substances were not kept in a locked place using a safe
locking method that prevent access by children.
Evidence:
1. In the Discovery Preschool 1 classroom, A Febreze spray was on top of the counter near the sink.
2. In the 2's Classroom B classroom, 3 spray bottles of multi-surface and disinfectant sanitizer were under the sink and not locked. The cabinet slides freely. A Lysol disinfectant spray was in a high level cabinet near the changing table unlocked and had the key in the lock.
3. In the infant classroom, Fabulosa, Sanitizer and air freshener were inside a lower cabinet under the changing table and were not kept locked. The cabinet opens if pushed.
Plan of Correction: All items have been moved and locked, higher cabinet.
Standard 8VAC20-780-290-A-3
Based on observation, unused electrical outlets were not covered with protective covers.
Evidence:
1. In the Discovery Preschool 2 classroom, 2 unused outlets to the right of the classroom were not covered with outlet covers.
Evidence:
1. In the Discovery Preschool 2 classroom, 2 unused outlets to the right of the classroom were not covered with outlet covers.
Plan of Correction: outlet covers will be placed in all empty outlets
Standard 8VAC20-780-50-A
Repeat Violation
Based on observation, staff and children's records were not treated confidentially.
Evidence:
1. The supplemental page from the inspection on 3/11/2024 was posted on the bulletin board. The page is considered confidential.
Based on observation, staff and children's records were not treated confidentially.
Evidence:
1. The supplemental page from the inspection on 3/11/2024 was posted on the bulletin board. The page is considered confidential.
Plan of Correction: Page will be taken down and furthermore, confidential pages will not be dislayed
Standard 8VAC20-780-500-A
Based on observation, the center is not following handwashing requirements.
Evidence:
1. In the Discovery Preschool 1 classroom, 8 children were observed eating snack/breakfast. When the children finished eating, the teachers stated to go to the carpet. The 8 children did not wash their hands with soap and running water after eating..
Evidence:
1. In the Discovery Preschool 1 classroom, 8 children were observed eating snack/breakfast. When the children finished eating, the teachers stated to go to the carpet. The 8 children did not wash their hands with soap and running water after eating..
Plan of Correction: Staff will be retrained in proper hand-washing procedures with the children
Standard 8VAC20-780-570-E
Based on observation, prepared infant formula was not dated.
Evidence:
1. In the Infant A classroom, 3 bottles were labeled with the child's name, but did not have a date.
Evidence:
1. In the Infant A classroom, 3 bottles were labeled with the child's name, but did not have a date.
Plan of Correction: children's bottles will be dated each day-parent reminders sent out
Standard 8VAC20-780-60-A
Repeat Violation
Based on record review, one of four children's records did not have complete information.
Evidence:
1. Child #4's file (start date 9/11/2024) was missing previous child day care and schools attended by the child..
Based on record review, one of four children's records did not have complete information.
Evidence:
1. Child #4's file (start date 9/11/2024) was missing previous child day care and schools attended by the child..
Plan of Correction: Parent and child files will be completed prior to start date
Standard 8VAC20-780-70
Based on review of records, staff records did not include all required information.
Evidence:
1. Staff #4 (Date of hire 8/13/2024) did not have 2 written references in the file.
Evidence:
1. Staff #4 (Date of hire 8/13/2024) did not have 2 written references in the file.
Plan of Correction: References will be printed off and placed in file