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St. Luke's United Methodist Church

Inspection · 2023-02-14

Date
2023-02-14
Complaint Related
No
Licensing Inspector
Molly Muscat
(804) 588-2367
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

22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
32.1 Report by person other than physician
54.1 Must be MAT Certified.
63.2 Child abuse and neglect
8VAC20-770 Background Checks
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services

Inspector Notes

An annual monitoring inspection was initiated on 02/14/2023 and concluded on 02/14/2023. The inspector was on site at the center from 10:30am to 12:42pm. There were 93 children in care with 18 staff supervising. Interviews were held with staff throughout the inspection, and the inspector interacted with children in each classroom when appropriate. The center?s playground and all classrooms were inspected today. Nine children?s records and nine employee records were reviewed during this inspection. Information gathered during the inspection determined areas of non-compliance with applicable regulations or law, and violations were documented on the violation notice issued to the vendor.

Violations

5
Standard 22.1-289.031-A-4
Based on record review, the center did not ensure each person in a supervisory position has been certified by a practicing physician or physician assistant to be free from any disability which would prevent him from caring for children under his supervision.
Evidence:
1. The record of staff #9 (employment date: 9/2022) did not have documentation showing that they have been certified by a practicing physician or physician assistant to be free from any disability which would prevent him from caring for children under his supervision.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-A
Based on record review, the facility failed to obtain repeat sworn statement or affirmation for four of nine staff within five years since the date of the last completed sworn statement or affirmation.
Evidence:
1. The record of staff #2 (employment date: 9/2017) had documentation of central registry results dated 9/24/17.
2. The record of staff #3 (employment date: 9/2017) had documentation of central registry results dated 10/18/17.
3. The record of staff #5 (employment date: 9/2016) had documentation of central registry results dated 10/18/17.
4. The record of staff #7 (employment date: 9/2016) had documentation of central registry results dated 10/17/17.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-B-2
Based on record review, the center did not ensure 1 of 9 staff records contained documentation of fingerprint based national criminal history search results prior to employment.
Evidence:
1. The record of staff #7 (employment date: 9/2020) had documentation of fingerprint based national criminal history search results dated 1/22/2021.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.058
Based on observation and an interview, the center did not ensure that the building serving preschool aged children was equipped with at least one carbon monoxide detector.
Evidence:
The licensing inspector did not see a carbon monoxide detector installed in the center. The center?s administrator stated that a carbon monoxide detector is not currently installed in the building.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-40-D-2
Based on record review, the provider did not ensure 3 of 9 staff records had documentation of central registry results within 30 days of employment and a completed sworn statement or affirmation prior to employment.
Evidence:
1. The record of staff #1 (employment date: 9/2001) did not have documentation of a completed sworn statement or affirmation.
2. The record of staff #7 (employment date: 9/2020) had documentation of central registry results dated 2/10/2021 and a completed sworn statement of affirmation dated 1/13/2021.
3. The record of staff #9 (employment date: 9/2022) did not have documentation of a completed sworn statement or affirmation and central registry results dated 10/25/2022.
Plan of Correction: Not available online. Contact Inspector for more information.
View original record on Virginia Department of Social Services