Inspection · 2023-09-08
Date
2023-09-08
Complaint Related
No
Licensing Inspector
Stephanie Salvatori
(571) 389-0980
(571) 389-0980
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.
20 Access to minor's records
22.1 Background Checks Code, Carbon Monoxide 54.1 Provider must be MAT certified to administer prescription medication.
63.2 Child abuse and neglect
Inspector Notes
An unannounced renewal inspection was conducted on 9/8/23 from 8:55 am to 11:35 m. There were 22 children in direct care and supervision of 7 staff members. The children were observed arriving to the center, engaged in circle time activities and playing with toys. 4 staff records, 3 children?s records, emergency drill logs, and other center documents were reviewed. The indoor and outdoor space used by children was inspected to ensure compliance. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were 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 return it to the department within 5 business days from receipt. Please specify how the deficient practice will be or has been corrected. Please do not use staff names; list staff by positions only. Any plans of correction not received within 5 business days will result in the plans not appearing on the Violation Notice and public website. For any questions regarding this inspection, please contact me at mahrukh.aziz@doe.virginia.gov or 571-835-4718.
Violations
13Standard 22.1-289.035-A
Based on record review, the center did not obtain the results of a repeat fingerprint based criminal record check (CRC), every five years for current employees.
Evidence:
1. Staff # 4?s most recent CRC was dated 4/7/18.
2. An updated CRC was not obtained for Staff # 4.
Evidence:
1. Staff # 4?s most recent CRC was dated 4/7/18.
2. An updated CRC was not obtained for Staff # 4.
Plan of Correction: Staff # 4 have been completed as of September 11, 2023. A copy was sent to the inspector on 10/4/23.
Standard 22.1-289.035-B-4
(Repeat Violation, Systemic Deficiency)
Based on records review, the center did not obtain results of an out of state central registry for employees that have resided outside of Virginia within the last five years, within 30 days of employment.
Evidence:
1. Staff # 2?s record indicated that Staff # 2 has lived in Maryland within the last 5 years.
2.Results of a Maryland central registry and sex offender search were not obtained for Staff # 2.
Based on records review, the center did not obtain results of an out of state central registry for employees that have resided outside of Virginia within the last five years, within 30 days of employment.
Evidence:
1. Staff # 2?s record indicated that Staff # 2 has lived in Maryland within the last 5 years.
2.Results of a Maryland central registry and sex offender search were not obtained for Staff # 2.
Plan of Correction: Background check has been obtained for Staff # 2. A Copy was sent to the inspector on 9.21.23.
Standard 8VAC20-770-60-B
Based on record review, the center did not obtain a complete Sworn Disclosure Statement (SDS) for each employee before the first day of employment.
Evidence:
1. Staff # 2?s first day of employment was 7/10/23.
2. Staff # 2?s record did not have a SDS.
Evidence:
1. Staff # 2?s first day of employment was 7/10/23.
2. Staff # 2?s record did not have a SDS.
Plan of Correction: Sworn disclosure for Staff # 2 was signed on 6/7/23. A copy was sent to the inspector on 10/4/23.
Standard 8VAC20-770-60-C-2
(Repeat Violation, Systemic Deficiency)
Based on records review, the center did not obtain result of a Virginia central registry check for an employee within 30 days of employment.
Evidence:
1. Staff # 2?s first day of employment was 7/10/23.
2. Staff # 2?s record did not have results of a Virginia central registry. There was no documentation on site to indicate whether or not a search request was submitted.
Based on records review, the center did not obtain result of a Virginia central registry check for an employee within 30 days of employment.
Evidence:
1. Staff # 2?s first day of employment was 7/10/23.
2. Staff # 2?s record did not have results of a Virginia central registry. There was no documentation on site to indicate whether or not a search request was submitted.
Plan of Correction: Background check was completed in 6/16/23. A copy was sent to the inspector on 10/4/23.
Standard 8VAC20-780-160-A
(Repeat Violation, Systemic Deficiency)
Based on records review, the center did not obtain results of a negative tuberculosis (TB) screening for each staff within 30 days prior to the first day of employment.
Evidence:
1. Staff # 2's hire date was 7/10/23.
2. Staff # 2's record did not include a TB screening.
Based on records review, the center did not obtain results of a negative tuberculosis (TB) screening for each staff within 30 days prior to the first day of employment.
Evidence:
1. Staff # 2's hire date was 7/10/23.
2. Staff # 2's record did not include a TB screening.
Plan of Correction: Staff # 2 has a negative TB test result from 3/20/22. A copy has been sent to the inspector on 10/4/23.
Standard 8VAC20-780-160-C
(Repeat Violation, Systemic Deficiency)
Based on record review, the center did not obtain a subsequent tuberculosis (TB) screening for staff, every two years.
Evidence: Staff # 5?s most recent TB screening expired on 3/29/21, and an updated screening was not obtained.
Based on record review, the center did not obtain a subsequent tuberculosis (TB) screening for staff, every two years.
Evidence: Staff # 5?s most recent TB screening expired on 3/29/21, and an updated screening was not obtained.
Plan of Correction: Staff # 5 had a TB test scheduled for 9/30/23 and we are awaiting the results. Results came back negative. A copy was sent to the inspector on 10.10.23.
Standard 8VAC20-780-270-A
(Repeat Violation, Systemic Deficiency)
Based on observation, areas inside and outside the center were not maintained in a clean and safe condition.
Evidence:
1. Areas of the tiled floor in the following classrooms were found to be unclean with dirt that appears to have accumulated over time: a. Preschool Classroom: Under and around the handwashing sink cabinet in the classroom, used by the children; tiled floor in front of the white vent, b. 2?s classroom: along the baseboard and under the cabinet of the diaper changing table and the door that leads into the toddler room.
2. One children?s sink in the Preschool classroom has a broken strip of plastic that covers the wood.
3. The pour in place resilient surfacing on the playground (in front of the school age classroom) was broken at three different spots, posing a trip hazard.
Based on observation, areas inside and outside the center were not maintained in a clean and safe condition.
Evidence:
1. Areas of the tiled floor in the following classrooms were found to be unclean with dirt that appears to have accumulated over time: a. Preschool Classroom: Under and around the handwashing sink cabinet in the classroom, used by the children; tiled floor in front of the white vent, b. 2?s classroom: along the baseboard and under the cabinet of the diaper changing table and the door that leads into the toddler room.
2. One children?s sink in the Preschool classroom has a broken strip of plastic that covers the wood.
3. The pour in place resilient surfacing on the playground (in front of the school age classroom) was broken at three different spots, posing a trip hazard.
Plan of Correction: The tile has been scheduled to be cleaned by 10/20/23. A work order has been placed to repair the broken strip of plastic that covers the wood surrounding the sink and the resilient surfacing on the playground. All will be cleaned and corrected by 10/20/23.
Standard 8VAC20-780-290-A-3
(Repeat Violation)
Based on observation, electric outlets were not covered by protective covers.
Evidence: One electric outlet in the Two's classroom and two electric outlets in the Toddler classroom were not covered by protective covers.
Based on observation, electric outlets were not covered by protective covers.
Evidence: One electric outlet in the Two's classroom and two electric outlets in the Toddler classroom were not covered by protective covers.
Plan of Correction: Covers have been replaced on all electrical outlets.
Standard 8VAC20-780-350-B-1
(Systemic Deficiency)
Based on observation and records review, the center did not maintain the 1 staff to 4 children ratio for children from birth through 16 months of age.
Evidence:
1. At approximately 9:23 am Child # 1 (15 months old) arrived to the Toddler room, where Staff # 1 was present with 5 children by herself. Child # 1 was the sixth child in her group.
2. Staff # 2 came into the Toddler classroom to help at 9:45 am.
3. The Toddler Room was out of ratio for approximately 22 minutes.
Based on observation and records review, the center did not maintain the 1 staff to 4 children ratio for children from birth through 16 months of age.
Evidence:
1. At approximately 9:23 am Child # 1 (15 months old) arrived to the Toddler room, where Staff # 1 was present with 5 children by herself. Child # 1 was the sixth child in her group.
2. Staff # 2 came into the Toddler classroom to help at 9:45 am.
3. The Toddler Room was out of ratio for approximately 22 minutes.
Plan of Correction: Management will ensure teachers are doing a name to face recognition check. If children become out of ratio teachers will immediately call for assistance using our walkie talkie system. Implemented immediately.
Standard 8VAC20-780-350-B-4
(Repeat Violation, Systemic Deficiency)
Based on observation and records review, the center did not maintain the 1 staff to 10 children ratio for children ranging from 3 years to 5 years old.
Evidence:
1. At approximately 9:03 am, Child # 2 (4 years old) arrived to the 3?4-year-old classroom where Staff # 3 was present with 10 children by herself.
2. Staff # 4 arrived at approximately 9:19 am to help Staff # 3.
3. The 3?4-year-old classroom was out of ratio for approximately 16 minutes.
Based on observation and records review, the center did not maintain the 1 staff to 10 children ratio for children ranging from 3 years to 5 years old.
Evidence:
1. At approximately 9:03 am, Child # 2 (4 years old) arrived to the 3?4-year-old classroom where Staff # 3 was present with 10 children by herself.
2. Staff # 4 arrived at approximately 9:19 am to help Staff # 3.
3. The 3?4-year-old classroom was out of ratio for approximately 16 minutes.
Plan of Correction: Management will ensure teachers are doing a name to face recognition check. If children become out of ratio teachers will immediately call for assistance using our walkie talkie system. Implemented immediately.
Standard 8VAC20-780-40-E
Repeat Violation, Systemic Deficiency
Based on records review and staff interview, the center did not follow its own policies and procedures that are required by the standards.
Evidence:
1. The center?s policies for the Child Supervision Records (CSR) states that ?Staff members responsible for the children must keep the CSR accurate and current at all times?.
2. On 9/8/23, a review of the CSR for the 3?4-year-old classroom showed that a staff member was signed in at 8:45 am. There was no name or signature with the time to identify the staff member.
3. The CSR for the 2?s classroom showed that Child # 3 arrived at 7:59 am on the date of the inspection, but Child # 3 was not in the classroom. Staff # 3 stated that Child # 3 was moved to the Toddler classroom. Child # 3?s exit from the 2?s classroom was not documented on their CSR. The CSR for the Toddler room showed Child # 3?s arrival was signed in at 9:02 am.
Based on records review and staff interview, the center did not follow its own policies and procedures that are required by the standards.
Evidence:
1. The center?s policies for the Child Supervision Records (CSR) states that ?Staff members responsible for the children must keep the CSR accurate and current at all times?.
2. On 9/8/23, a review of the CSR for the 3?4-year-old classroom showed that a staff member was signed in at 8:45 am. There was no name or signature with the time to identify the staff member.
3. The CSR for the 2?s classroom showed that Child # 3 arrived at 7:59 am on the date of the inspection, but Child # 3 was not in the classroom. Staff # 3 stated that Child # 3 was moved to the Toddler classroom. Child # 3?s exit from the 2?s classroom was not documented on their CSR. The CSR for the Toddler room showed Child # 3?s arrival was signed in at 9:02 am.
Plan of Correction: Management will ensure that CSR's are accurate and completed daily with staff paying attention to signing the CSR's for both themselves and the children in care. Implemented immediately.
Standard 8VAC20-780-550-G
Based on records review, the center did not maintain documentation of evacuation drills.
Evidence:
1. Fire drills for June, July and August 2023 were not documented on the evacuation drill log.
2. Staff # 4 and Staff # 6 verbally confirmed that evacuation drills were completed but not documented on their log.
Evidence:
1. Fire drills for June, July and August 2023 were not documented on the evacuation drill log.
2. Staff # 4 and Staff # 6 verbally confirmed that evacuation drills were completed but not documented on their log.
Plan of Correction: All future drills will be recorded accurately in the log sheet.
Standard 8VAC20-780-550-P
Based on records review, the written records of children?s injuries did not contain complete information.
Evidence: A review of three incident reports for children?s minor injuries did not have the following information: 1. Date/time when parent was notified and documentation of how the parents were notified.
Evidence: A review of three incident reports for children?s minor injuries did not have the following information: 1. Date/time when parent was notified and documentation of how the parents were notified.
Plan of Correction: Staff has been notified to be sure that forms are completed in there and management will ensure that when the forms are submitted they are accurate. Implemented immediately.