Inspection · 2023-03-28
Date
2023-03-28
Complaint Related
No
Licensing Inspector
Tara Barton
(804) 381-8487
(804) 381-8487
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
A monitoring inspection was conducted Tuesday, March 28, 2023 and concluded on Friday, March 31, 2023. On Tuesday, March 28, 2023 the licensing inspector was onsite, completing the inspection from approximately 11:00pm until 3:00pm. There were 67 children present, ranging in ages from three months to five years, with 12 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, and medication. A total of seven children's records and six staff members? records were reviewed.
Information gathered during the inspection determined non-compliance with applicable standards or law and a violation was documented on the violation notice issued to the program.
Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to me within five business days from today. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
If you have any questions about this inspection, please contact the licensing inspector at (804) 840-8260.
Lynn Powers
Office of Child Care Health and Safety
Division of Early Childhood Care and Education
Phone# 804-840-8260
lynn.powers@doe.virginia.gov
Violations
14Standard 22.1-289.035-A
Based on a review of six staff records, observation, and documentation review, the center did not ensure one staff obtained background checks every five years.
Evidence:
1. The record for Staff #2 (date of employment 10/13/2008) contained the results of a fingerprint national criminal record check dated 03/26/2018 and a sworn statement dated 01/31/2018.
2. Staff #2 was observed working and being counted in the staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Evidence:
1. The record for Staff #2 (date of employment 10/13/2008) contained the results of a fingerprint national criminal record check dated 03/26/2018 and a sworn statement dated 01/31/2018.
2. Staff #2 was observed working and being counted in the staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Plan of Correction: Staff #2 was given paperwork to complete new fingerprints on 04/19/2023, as well as completed new sworn statement.
Standard 22.1-289.035-B-2
Based on review of six staff records, observation, and documentation review, the center did not ensure staff underwent a fingerprint based national criminal prior to employment for one staff member.
Evidence:
1. The record of Staff #1 (date of employment 02/21/2023) did not contain documentation of a fingerprint based national criminal background check.
2. Staff #1 was observed working and being counted in the staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Evidence:
1. The record of Staff #1 (date of employment 02/21/2023) did not contain documentation of a fingerprint based national criminal background check.
2. Staff #1 was observed working and being counted in the staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Plan of Correction: Both managers will sign off new hire documentation checklist to ensure paperwork is not overlooked. Fingerprint apt. (sic) for Staff #1 is set.
Standard 8VAC20-770-60-C-2
Based on review of six staff records observation, and documentation review, the center did not obtain documentation of central registry findings within 30 days of employment for two staff members.
Evidence:
1. The record of Staff #1 (date of employment 02/21/2023) did not contain documentation of central registry findings. Documentation in the record indicated the central registry findings was requested on 03/06/2023. Staff #1 was observed working and counting in the staff-to-child ratio during the inspection.
2. The record of Staff #5 (date of employment 11/30/2022) did not contain documentation of central registry findings. There was no documentation of the central registry findings being requested. Staff #5 was observed working and counting in the staff-to-child ratio during the inspection.
3. The record of Staff #6 (date of employment 11/15/2022) did not contain documentation of central registry findings. Documentation in the record indicated the central registry findings was requested on 02/06/2023. Staff #6 was observed working and counting in the staff-to-child ratio during the inspection.
4. A member of management confirmed this information by email on 03/31/2023.
Evidence:
1. The record of Staff #1 (date of employment 02/21/2023) did not contain documentation of central registry findings. Documentation in the record indicated the central registry findings was requested on 03/06/2023. Staff #1 was observed working and counting in the staff-to-child ratio during the inspection.
2. The record of Staff #5 (date of employment 11/30/2022) did not contain documentation of central registry findings. There was no documentation of the central registry findings being requested. Staff #5 was observed working and counting in the staff-to-child ratio during the inspection.
3. The record of Staff #6 (date of employment 11/15/2022) did not contain documentation of central registry findings. Documentation in the record indicated the central registry findings was requested on 02/06/2023. Staff #6 was observed working and counting in the staff-to-child ratio during the inspection.
4. A member of management confirmed this information by email on 03/31/2023.
Plan of Correction: Management issued a new online request for background checks for staff without results.
Standard 8VAC20-780-130-E
Based on review of seven children?s records and observation, the center did not obtain documentation of additional immunizations once every six months for one child under the age of two years.
Evidence:
1. The record for Child #3 (first date of attendance 01/22/2021) contained immunization documentation dated 01/21/2021. Child #3 turned two years of age in May 2022.
2. Child #3 was observed present and counted in the staff-to-child ratio during the inspection.
Evidence:
1. The record for Child #3 (first date of attendance 01/22/2021) contained immunization documentation dated 01/21/2021. Child #3 turned two years of age in May 2022.
2. Child #3 was observed present and counted in the staff-to-child ratio during the inspection.
Plan of Correction: Center-wide message has been sent to parents to request new documentation that reflects update medical records.
Standard 8VAC20-780-160-A
Based on review of six staff records, observation, and documentation review, the center did not ensure one staff member submitted documentation of a negative tuberculosis (TB) screening that had been completed within the last 30 calendar days prior of the date of employment.
Evidence:
1. The record for Staff #6 (date of employment 11/15/2022) did not contain documentation of a negative TB screening.
2. Staff #6 was counted in the staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Evidence:
1. The record for Staff #6 (date of employment 11/15/2022) did not contain documentation of a negative TB screening.
2. Staff #6 was counted in the staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Plan of Correction: TB screening will be complete by 4/28.
Standard 8VAC20-780-160-C
Based on review of six staff records, observation and documentation review, the center did not ensure three staff members obtained and submitted documentation of a follow-up tuberculosis (TB) screening at least every two years from the date of the initial screening.
Evidence:
1. The record for Staff #2 (Date of Employment 10/13/2008) contained a TB screening dated 06/19/2019.
2. The record for Staff #3 (Date of Employment 01/21/2021) contained a TB screening dated 01/21/2021.
3. The record for Staff #4 (Date of Employment 03/01/2020) contained a TB screening dated 03/12/2020.
4. Staff #2, Staff #3, and Staff #4 was observed working and counting in the staff-to-child ratio during the inspection.
5. A member of management confirmed this information by email on 03/31/2023.
Evidence:
1. The record for Staff #2 (Date of Employment 10/13/2008) contained a TB screening dated 06/19/2019.
2. The record for Staff #3 (Date of Employment 01/21/2021) contained a TB screening dated 01/21/2021.
3. The record for Staff #4 (Date of Employment 03/01/2020) contained a TB screening dated 03/12/2020.
4. Staff #2, Staff #3, and Staff #4 was observed working and counting in the staff-to-child ratio during the inspection.
5. A member of management confirmed this information by email on 03/31/2023.
Plan of Correction: TB screenings of expired staff will be complete by 5/5.
Standard 8VAC20-780-240-A
Based on review of six staff records, observation, and documentation review, the center did not ensure two staff completed the Virginia Department of Education-sponsored orientation course within 90 days of employment.
Evidence:
1. The records of Staff #5 (date of employment 11/30/2022) and Staff #6 (date of employment 11/15/2022) did not contain documentation of completing the Virginia Department of Education-sponsored orientation course within 90 days of employment.
2. Staff #5 and Staff #6 was observed working and counting in staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Evidence:
1. The records of Staff #5 (date of employment 11/30/2022) and Staff #6 (date of employment 11/15/2022) did not contain documentation of completing the Virginia Department of Education-sponsored orientation course within 90 days of employment.
2. Staff #5 and Staff #6 was observed working and counting in staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Plan of Correction: Staff without VDOE training are required to complete by 5/5. All new staff will be required to complete within first week.
Standard 8VAC20-780-270-A
Based on observation, the center did not maintain all areas and equipment of the center, inside and outside, in a clean, safe, and operable condition.
Evidence:
1. Four tricycles located on the side outdoor playground, were missing the pedals, leaving the metal spokes exposed.
2. The metal gate separating the School Age playground and the Preschool playground was broken and hanging off the top hinge, creating components that could tangle clothing or snag skin.
Evidence:
1. Four tricycles located on the side outdoor playground, were missing the pedals, leaving the metal spokes exposed.
2. The metal gate separating the School Age playground and the Preschool playground was broken and hanging off the top hinge, creating components that could tangle clothing or snag skin.
Plan of Correction: Management removed all broken tricycles from playground. Work order had already been entered for gate. CD reached out to facilities for update.
Standard 8VAC20-780-290-A-3
Based on observation, the center did not ensure electrical outlets had protective covers.
Evidence:
Two outlets located on the walls of the Two?s classroom did not contain protective outlet covers. There were 18 children (two and three years of age) in the classroom during the inspection.
Evidence:
Two outlets located on the walls of the Two?s classroom did not contain protective outlet covers. There were 18 children (two and three years of age) in the classroom during the inspection.
Plan of Correction: Management walked entire building and covered any exposed outlets.
Standard 8VAC20-780-340-A
Based on observations, the center failed to ensure that when staff are supervising children, they shall always ensure their care, protection, and guidance.
Evidence:
From approximately 12:10pm until 12:35pm, Staff #1, Staff #3 and Staff #6 were observed changing diapers, cleaning up after lunch, and laying out cots for naptime with 18 children present in the Two?s classroom (Two?s and Three?s classrooms were combined for the day).
The following was observed in the classroom during this approximate time frame:
1. Four children jumped off seven stacked cots (total height approximately 18 inches) at least seven times onto the tile floor.
2. Three cots were leaned against the exterior door leading to the playground. Two children ran up the inclined cots, jumping onto the tile floor at least five times. Child #1 fell and began to cry. Child #1 was comforted by Child #3.
3. Two children were observed climbing on top of a toy shelf (total height approximately 24 inches) and jumping onto a child size couch approximately two feet away at least four times.
4. Three children were observed in the classroom?s bathroom, playing with a plunger in the toilets and hitting each other with the wet plunger.
Evidence:
From approximately 12:10pm until 12:35pm, Staff #1, Staff #3 and Staff #6 were observed changing diapers, cleaning up after lunch, and laying out cots for naptime with 18 children present in the Two?s classroom (Two?s and Three?s classrooms were combined for the day).
The following was observed in the classroom during this approximate time frame:
1. Four children jumped off seven stacked cots (total height approximately 18 inches) at least seven times onto the tile floor.
2. Three cots were leaned against the exterior door leading to the playground. Two children ran up the inclined cots, jumping onto the tile floor at least five times. Child #1 fell and began to cry. Child #1 was comforted by Child #3.
3. Two children were observed climbing on top of a toy shelf (total height approximately 24 inches) and jumping onto a child size couch approximately two feet away at least four times.
4. Three children were observed in the classroom?s bathroom, playing with a plunger in the toilets and hitting each other with the wet plunger.
Plan of Correction: Management will do in-classroom coaching/modeling of proper transition activities. Have partnered with ChildSavers to have trainers come to work to with staff on behavior/classroom management. May staff meeting 5/18.
Standard 8VAC20-780-500-A
Based on observation, the center failed to follow required diapering procedures.
Evidence:
The following observations were made on March 28, 2023 in the Two?s classroom (Two?s and Three?s classrooms were combined for the day).
1. Staff #1 was observed changing five children?s diapers. After completing the diaper changes, Staff #1 was observed using her hands to lift the trash can lid to dispose of the soiled diapers. Staff are to ensure the diaper disposal system was either foot-operated or used in such a way that neither the staff member's hand nor the soiled diaper touched an exterior surface of the storage system during disposal.
2. Staff #1 was observed changing five children in the Two?s classroom. Staff #1 did not clean and sanitize the diaper changing table after each use.
Evidence:
The following observations were made on March 28, 2023 in the Two?s classroom (Two?s and Three?s classrooms were combined for the day).
1. Staff #1 was observed changing five children?s diapers. After completing the diaper changes, Staff #1 was observed using her hands to lift the trash can lid to dispose of the soiled diapers. Staff are to ensure the diaper disposal system was either foot-operated or used in such a way that neither the staff member's hand nor the soiled diaper touched an exterior surface of the storage system during disposal.
2. Staff #1 was observed changing five children in the Two?s classroom. Staff #1 did not clean and sanitize the diaper changing table after each use.
Plan of Correction: New trash cans have been purchased for all classrooms. Diapering rooms have new cans with working foot pedals. All staff has been retrained on proper diapering procedures.
Standard 8VAC20-780-500-B
Based on observation, the center did not ensure bottles are not propped or used while a child is in a designated sleeping location.
Evidence:
Child #2 was observed drinking a bottle while laying on a cot while the classroom was transitioning into naptime during the inspection.
Evidence:
Child #2 was observed drinking a bottle while laying on a cot while the classroom was transitioning into naptime during the inspection.
Plan of Correction: Infant teachers were retrained on proper bottle usage/safe sleep.
Standard 8VAC20-780-60-A-8
Based on review of seven children?s records, observation and documentation review, the center did not ensure documentation of a written care plan for one child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
Evidence:
1. The record of Child #4 (first date of attendance 10/10/2022) did not have documentation of a written care plan to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
2. The record of Child #4 had documentation of a diagnosed food allergy.
3. The Master Allergy List located in the center and dated March 2023, listed Child #4 as having a food allergy.
Evidence:
1. The record of Child #4 (first date of attendance 10/10/2022) did not have documentation of a written care plan to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
2. The record of Child #4 had documentation of a diagnosed food allergy.
3. The Master Allergy List located in the center and dated March 2023, listed Child #4 as having a food allergy.
Plan of Correction: Child 4 was given a new allergy plan to have completed by physician. All other students on allergy list had files checked for proper documentation by management 04/19/2023.
Standard 8VAC20-780-70
Based on review of six staff records, observation, and documentation review, the center did not keep the required records for three staff.
Evidence:
1. The records for Staff #2 (Date of Employment 10/13/2008), Staff #3 (Date of Employment 01/21/2021), and Staff #4 (Date of Employment 03/01/2020) did not contain documentation of staff completing a minimum of 16 hours of annual training appropriate to the age of children in care, for the prior year.
2. Staff #3 was identified as a program leader during the inspection. The record of Staff #3 (Date of Employment 01/21/2021) did not contain documentation of education required for the job position.
3. Staff #2, Staff #3 and Staff #4 were observed working and being counted in the staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Evidence:
1. The records for Staff #2 (Date of Employment 10/13/2008), Staff #3 (Date of Employment 01/21/2021), and Staff #4 (Date of Employment 03/01/2020) did not contain documentation of staff completing a minimum of 16 hours of annual training appropriate to the age of children in care, for the prior year.
2. Staff #3 was identified as a program leader during the inspection. The record of Staff #3 (Date of Employment 01/21/2021) did not contain documentation of education required for the job position.
3. Staff #2, Staff #3 and Staff #4 were observed working and being counted in the staff-to-child ratio during the inspection.
3. A member of management confirmed this information by email on 03/31/2023.
Plan of Correction: Training logs have been added to all staff files to document hours spent in training. Management is working on completing back logs of all trainings completed thus far in 2023.