Inspection · 2024-08-30
Date
2024-08-30
Complaint Related
No
Licensing Inspector
Rene Old
(757) 404-1784
(757) 404-1784
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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced, on-site monitoring inspection was initiated on 8/30/2024 and completed on 8/30/2024. The on-site inspection began at 10:36 am and ended at 1:40 pm. The inspector reviewed compliance in the areas listed above. There were 77 children present and 15 staff. The inspector reviewed 9 children's records and 8 staff records on-site.
This inspection included:
*Document review ( injury logs, emergency drill logs, written policies, medication and medication administration logs and authorization forms);
*Tour of the facility and outdoor play areas;
*Interviews;
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 09/12/2024. A POC submitted after this date will not appear on the public website.
Violations
10Standard 22.1-289.035-B-3
Based on record review and interview, the center failed to obtain a copy of the results of a search of the central registry maintained pursuant to ? 63.2-1515 for any founded complaint of child abuse or neglect against him.
Evidence:
1. Staff 1, hire date 06/17/2024, lacks the results of a central registry check.
2. Staff 2, hire date 06/13/2024, lacks the results of a central registry check.
3. The program director stated she did not have the results of a central registry check for staff 1 and staff 2.
Evidence:
1. Staff 1, hire date 06/17/2024, lacks the results of a central registry check.
2. Staff 2, hire date 06/13/2024, lacks the results of a central registry check.
3. The program director stated she did not have the results of a central registry check for staff 1 and staff 2.
Plan of Correction: Staff 1 had been submitted but was returned for an error and has since been resubmitted. Staff 2 was transferred from another center so their original request was processed at that location and was pending results. A new request has been submitted for staff 2 for this location. We have scheduled weekly follow-ups until these results are received. Moving forward, Center Management will ensure all required documents are in new hire's file on day 1 of employment.
Standard 22.1-289.035-B-4
Based on record review and interview, the center failed to obtain a copy of the results of a criminal history record information check and a search of the child abuse and neglect registry or equivalent registry from any state in which the individual has resided in the preceding five years.
Evidence:
1. The results of a criminal record check and a search of the child abuse and neglect registry for another state that staff 3 has resided in within the past 5 years were not on file.
a. Staff 3 had provided written information on the sworn statement or affirmation that stated a residence outside of Virginia within the past 5 years.
b. Staff 3 has a hire date of 10/20/2023.
2. The results of a criminal record check and a search of the child abuse and neglect registry for another state that staff 4 has resided in within the past 5 years were not on file.
a. Staff 4 had provided written information on the sworn statement or affirmation that stated a residence outside of Virginia within the past 5 years.
b. Staff 4 has a hire date of 7/1/2024.
3. The program director stated that out-of-state background checks were not on file for staff 3 and staff 4.
Evidence:
1. The results of a criminal record check and a search of the child abuse and neglect registry for another state that staff 3 has resided in within the past 5 years were not on file.
a. Staff 3 had provided written information on the sworn statement or affirmation that stated a residence outside of Virginia within the past 5 years.
b. Staff 3 has a hire date of 10/20/2023.
2. The results of a criminal record check and a search of the child abuse and neglect registry for another state that staff 4 has resided in within the past 5 years were not on file.
a. Staff 4 had provided written information on the sworn statement or affirmation that stated a residence outside of Virginia within the past 5 years.
b. Staff 4 has a hire date of 7/1/2024.
3. The program director stated that out-of-state background checks were not on file for staff 3 and staff 4.
Plan of Correction: Out of State Background Check had been previously submitted for both employees with results still pending. Both have since been resubmitted and the requests have been placed in their files. Follow-up scheduled weekly until results are received. Moving forward, Center Management will ensure all required documents are in new hire's file on day 1 of employment.
Standard 8VAC20-780-130-E
Repeat Violation:
Based on record review and interview, the center failed to obtain documentation of additional immunizations once every six months for children under the age of two years.
Evidence:
1. The most recent immunizations for child 1, age 32 months, were administered on 04/14/2022.
a. There was no documentation to confirm that child 1 received all immunizations required for children between the age of 6 months and 2 years.
2. The most recent immunizations for child 5, age 11 months, were administered on 12/04/2023.
3. The most recent immunizations for child 6, age 10 months, were administered on 12/14/2023.
3. The program director stated that updated immunization documentation could not be located for child 1, child 5 and child 6.
Based on record review and interview, the center failed to obtain documentation of additional immunizations once every six months for children under the age of two years.
Evidence:
1. The most recent immunizations for child 1, age 32 months, were administered on 04/14/2022.
a. There was no documentation to confirm that child 1 received all immunizations required for children between the age of 6 months and 2 years.
2. The most recent immunizations for child 5, age 11 months, were administered on 12/04/2023.
3. The most recent immunizations for child 6, age 10 months, were administered on 12/14/2023.
3. The program director stated that updated immunization documentation could not be located for child 1, child 5 and child 6.
Plan of Correction: Center Management is working with families to get these immunizations updated no later than 9/20/2024 in order to continue care. Moving forward, we will continue to ensure immunizations are up to date based on state requirements by age. We are inputting all child file immunization dates into a spreadsheet to proactively address any immunizations that will be expiring in the near future.
Standard 8VAC20-780-140-A
Repeat Violation
Based on record review and interview, the center failed to ensure that each child shall have a physical examination by or under the direction of a physician before the child's attendance; or within 30 days after the first day of attendance.
Evidence:
1. Child 1, enrollment date 04/18/2022, lacked documentation of a physical exam.
2. Child 2, enrollment date 09/06/2022, lacked documentation of a physical exam.
3. Both children were in care during the inspection and the director confirmed that a physical exam was not on file for child 1 and child 2.
Based on record review and interview, the center failed to ensure that each child shall have a physical examination by or under the direction of a physician before the child's attendance; or within 30 days after the first day of attendance.
Evidence:
1. Child 1, enrollment date 04/18/2022, lacked documentation of a physical exam.
2. Child 2, enrollment date 09/06/2022, lacked documentation of a physical exam.
3. Both children were in care during the inspection and the director confirmed that a physical exam was not on file for child 1 and child 2.
Plan of Correction: Center Management is working with families to get these physicals submitted no later than 9/20/2024 in order to continue care. Moving forward, we will continue to ensure records are complete before day 1 of enrollment.
Standard 8VAC20-780-160-A
Based on record review and interview, the center failed to ensure that the documentation of the required TB screening shall have been completed within the last 30 calendar days of the date of employment.
Evidence:
1. The TB screening for staff 5 was completed on 4/4/2024 which is after her hire date of 3/25/2024.
2. The TB screening for staff 6 was completed on 5/16/2023 which is after her hire date of 5/8/2023.
3. The TB screening for staff 7 was completed on 12/19/2023 which is after her hire date of 8/21/2023.
4. The program director confirmed that the TB screening for these staff had been obtained after employment.
Evidence:
1. The TB screening for staff 5 was completed on 4/4/2024 which is after her hire date of 3/25/2024.
2. The TB screening for staff 6 was completed on 5/16/2023 which is after her hire date of 5/8/2023.
3. The TB screening for staff 7 was completed on 12/19/2023 which is after her hire date of 8/21/2023.
4. The program director confirmed that the TB screening for these staff had been obtained after employment.
Plan of Correction: Staff 5, 6, and 7 all transferred from another center so we are unable to correct the past error on TB test time frame. Moving forward, we will continue to require that all new staff have their TB testing completed no more than 30 days before hire.
Standard 8VAC20-780-270-A
Based on observation, the center failed to ensure that outside areas of the center shall be maintained in a safe condition.
Evidence:
1. There is an area of sidewalk that no longer meets flush with the ground on the preschool outdoor play area. This gap is a trip hazard.
Evidence:
1. There is an area of sidewalk that no longer meets flush with the ground on the preschool outdoor play area. This gap is a trip hazard.
Plan of Correction: Work order has been placed for sidewalk not being flush; Center Director is working with Facilities Manager to get issue escalated. Center Management will continue to complete daily playground safety checklist to look for any new issues to submit a Work Order for and have issues addressed.
Standard 8VAC20-780-330-B
Based on observation, the center to ensure where playground equipment is provided, resilient surfacing shall comply with minimum safety standards.
Evidence:
1. The mulch surrounding the outdoor play structure on the preschool playground measured between 2 and 3 inches in depth in all areas of the fall zone.
a. A depth of 6 inches is required.
Evidence:
1. The mulch surrounding the outdoor play structure on the preschool playground measured between 2 and 3 inches in depth in all areas of the fall zone.
a. A depth of 6 inches is required.
Plan of Correction: Work Order has been placed for resilient surfacing; Center Director is working with Facilities Manager to get this issue escalated.
Standard 8VAC20-780-420-E-3
Based on record review and interview, the center failed to request at least annually parent confirmation that the required information in the child's record is up to date. Such sharing of information shall be documented.
Evidence:
1. There was no written documentation to confirm annual review and update of the record for child 1. Child 1 has an enrollment date of 4/18/2022.
2. There was no written documentation to confirm annual review and update of the record for child 2. Child 2 has an enrollment date of 9/6/2022.
3. There was no written documentation to confirm annual review and update of the record for child 3. Child 3 has an enrollment date of 9/6/2022.
4. The program director confirmed that documentation was not available of an annual review and update by each child's parent.
Evidence:
1. There was no written documentation to confirm annual review and update of the record for child 1. Child 1 has an enrollment date of 4/18/2022.
2. There was no written documentation to confirm annual review and update of the record for child 2. Child 2 has an enrollment date of 9/6/2022.
3. There was no written documentation to confirm annual review and update of the record for child 3. Child 3 has an enrollment date of 9/6/2022.
4. The program director confirmed that documentation was not available of an annual review and update by each child's parent.
Plan of Correction: Center Management is working with families to get these annual signatures updated for the 2024 school year in order to continue care. Moving forward, we will ensure these annual signatures updates are completed every summer before the new school year begins to remain in compliance.
Standard 8VAC20-780-60-A
Repeat Violation
Based on record review and interview, the center failed to ensure that children's records contain all of the required elements.
Evidence:
1. The enrollment record for child 1, enrollment date 4/18/2022, lacked documentation of two designated emergency contacts and viewing proof of age and identity.
2. The enrollment record for child 2, enrollment date 9/6/2022, lacked documentation of an address for the two emergency contacts and viewing proof of age and identity.
3. The enrollment record for child 3, enrollment date 09/06/2022, lacked documentation of the home address for one parent and one parent's place of employment and work telephone number. Additionally, documentation of viewing proof of child 3's age and identity was not on file.
4. The enrollment record for child 4, enrollment date 06/03/2024, lacked documentation of a second emergency contact.
5. The enrollment record for child 5, enrollment date 12/18/2023, lacked documentation of a second emergency contact and verification of viewing proof of the child's identity and age.
6. The enrollment record for child 6 lacked documentation of the place of employment and a work telephone number for both parents.
6. The program director confirmed that the above information was not available.
Based on record review and interview, the center failed to ensure that children's records contain all of the required elements.
Evidence:
1. The enrollment record for child 1, enrollment date 4/18/2022, lacked documentation of two designated emergency contacts and viewing proof of age and identity.
2. The enrollment record for child 2, enrollment date 9/6/2022, lacked documentation of an address for the two emergency contacts and viewing proof of age and identity.
3. The enrollment record for child 3, enrollment date 09/06/2022, lacked documentation of the home address for one parent and one parent's place of employment and work telephone number. Additionally, documentation of viewing proof of child 3's age and identity was not on file.
4. The enrollment record for child 4, enrollment date 06/03/2024, lacked documentation of a second emergency contact.
5. The enrollment record for child 5, enrollment date 12/18/2023, lacked documentation of a second emergency contact and verification of viewing proof of the child's identity and age.
6. The enrollment record for child 6 lacked documentation of the place of employment and a work telephone number for both parents.
6. The program director confirmed that the above information was not available.
Plan of Correction: Center Management is working with families to get files in compliance no later than 9/20/2024 in order to continue care. Moving forward, we will continue to ensure records are complete before the 1st day of enrollment.
Standard 8VAC20-780-70
Repeat Violation
Based on staff record review and interview, the center failed to ensure that staff records contain all of the required elements:
1. The employment file for staff 1, hire date 06/17/2024, lacked written documentation that two reference checks were completed prior to employment.
Based on staff record review and interview, the center failed to ensure that staff records contain all of the required elements:
1. The employment file for staff 1, hire date 06/17/2024, lacked written documentation that two reference checks were completed prior to employment.
Plan of Correction: References were completed for staff 1 before her hire date, however we are unable to locate them. Center Management will redo and place in file no later than 9/16/2024. Moving forward, Center Management will continue to complete reference checks prior to 1st day of employment.