Inspection · 2025-01-24
Date
2025-01-24
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
During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.
Inspector Notes
An unannounced, on-site renewal inspection was initiated on 01/24/2025 and completed on 01/24/2025. The on-site inspection began at 12:10 pm and ended at 4:35 pm. The inspector reviewed compliance in the areas listed above. There were 70 children present and 11 staff. The inspector reviewed 8 children's records and 10 records on-site.
The inspection included:
*Document Review
*Tour of the Facility
*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 ow the violation will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 02/06/2025. A POC submitted after this date will not appear on the public website.
Violations
9Standard 22.1-289.035-B-3
Repeat Violation
The child day center shall 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.
1. The results of a central registry check were not on file for staff 3 who has been employed for more than 30 days. Staff 3 was observed alone with a group of children during the inspection.
2. The results of a central registry check were not on file for staff 4 and staff 5. Both staff have been employed for more than 60 days.
The child day center shall 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.
1. The results of a central registry check were not on file for staff 3 who has been employed for more than 30 days. Staff 3 was observed alone with a group of children during the inspection.
2. The results of a central registry check were not on file for staff 4 and staff 5. Both staff have been employed for more than 60 days.
Plan of Correction: -Center Director has resubmitted central registry reports for staff 3, staff 4 and staff 5. Staff 3 will no longer be scheduled alone in classrooms, until the results from CRS are complete.
-Center Director will reach out bi-weekly until results are returned.
-Moving forward all new staff will complete CRS before hire, and submission will be documented and placed in staff's file, with bi-weekly checks until results are completed.
-Center Director will reach out bi-weekly until results are returned.
-Moving forward all new staff will complete CRS before hire, and submission will be documented and placed in staff's file, with bi-weekly checks until results are completed.
Standard 22.1-289.035-B-4
Repeat Violation
The child day center shall obtain a copy of the results of a criminal history record information check, a sex offender registry 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.
1. There was no central registry check for a state, outside of Virginia, that staff 1 has resided in within the past five years. Staff 1 has been employed at the center for more than 6 months.
2. There was no out-of-state central registry check and sex offender check for two states that staff 2 has resided in within the past five years. Additionally, an out-of-state criminal record check is not on file for one of these states. Staff 2 has been employed at the center for more than seven months.
3. There was no out-of-state central registry check from one state that staff 3 has resided in within the past five years. Additionally, there was no out-of-state criminal record check for a second state that staff 3 has resided in within the past five years. Staff 3 has been employed for more than 30 days.
The child day center shall obtain a copy of the results of a criminal history record information check, a sex offender registry 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.
1. There was no central registry check for a state, outside of Virginia, that staff 1 has resided in within the past five years. Staff 1 has been employed at the center for more than 6 months.
2. There was no out-of-state central registry check and sex offender check for two states that staff 2 has resided in within the past five years. Additionally, an out-of-state criminal record check is not on file for one of these states. Staff 2 has been employed at the center for more than seven months.
3. There was no out-of-state central registry check from one state that staff 3 has resided in within the past five years. Additionally, there was no out-of-state criminal record check for a second state that staff 3 has resided in within the past five years. Staff 3 has been employed for more than 30 days.
Plan of Correction: -Center Director has resubmitted out- of -state central registry reports for staff 1, staff 2 and staff 3. Additionally, staff 2 criminal background and sex offender for the out-of-state has been requested.
-Center Director will make bi weekly check, until results are completed.
-Moving forward all new staff will have complete central registry, criminal history, and sex offender searches completed before their first day of employment.
-Center Director will make bi weekly check, until results are completed.
-Moving forward all new staff will have complete central registry, criminal history, and sex offender searches completed before their first day of employment.
Standard 8VAC20-780-160-B
Acceptable forms of documentation of tuberculosis screening shall be signed by a physician and include the date the test or screening was conducted and the results for the individual.
The TB screening for staff 6 lacked the signature of the physician or his designee and any identifying information to confirm who the test had been conducted for. Staff 6 has been employed for more than four months.
The TB screening for staff 6 lacked the signature of the physician or his designee and any identifying information to confirm who the test had been conducted for. Staff 6 has been employed for more than four months.
Plan of Correction: -Staff 6 has completed a new TB screening.
-Moving forward Center Director will obtain a TB screening for all employees within 30 days previous to employment for all new employees, that clearly shows the employee's name and doctor's signature.
-Moving forward Center Director will obtain a TB screening for all employees within 30 days previous to employment for all new employees, that clearly shows the employee's name and doctor's signature.
Standard 8VAC20-780-420-E-3
Repeat Violation
The center shall request at lease annually parent confirmation that the required information in the child's record is up to date. Shall sharing of information shall be documented.
There was no written documentation of annual review and update for the enrollment records of child 2 and child 3. Both children have been in care for more than 12 months.
The center shall request at lease annually parent confirmation that the required information in the child's record is up to date. Shall sharing of information shall be documented.
There was no written documentation of annual review and update for the enrollment records of child 2 and child 3. Both children have been in care for more than 12 months.
Plan of Correction: -The annual updates and signatures have been completed for child 2 and child 3.
-Moving forward Center Director is having all families sign off on child's files update every August, regardless of enrollment date.
-Moving forward Center Director is having all families sign off on child's files update every August, regardless of enrollment date.
Standard 8VAC20-780-520-C
If diaper ointment or cream is used, the following requirements shall be met:
The product shall be labeled with the child's name.
One diaper ointment, for child 5, was not labeled with her name.
The product shall be labeled with the child's name.
One diaper ointment, for child 5, was not labeled with her name.
Plan of Correction: -All diaper ointment or cream was labeled with child 5's name during the inspection.
-Moving forward management will require all over the counter medications be brought to the office, inspected by management, then delivered to the classroom, if all standards are met.
-Moving forward management will require all over the counter medications be brought to the office, inspected by management, then delivered to the classroom, if all standards are met.
Standard 8VAC20-780-540-E
The following nonmedical emergency supplies shall be required: One working, battery-operated radio.
The battery-operated was not working during the inspection.
The battery-operated was not working during the inspection.
Plan of Correction: -Director was able to get the radio to work when she returned to the school, but on the suggestion of the inspector an "old fashioned" battery powered weather radio was purchased for the school's non-medical emergency kit.
Standard 8VAC20-780-550-P
The record of children's minor injuries shall contain all of the required elements.
Five of five injury reports reviewed lacked the following required documentation:
* Any future action to prevent recurrence of the injury;
* A second signature form a staff person.
Five of five injury reports reviewed lacked the following required documentation:
* Any future action to prevent recurrence of the injury;
* A second signature form a staff person.
Plan of Correction: -Center Director has replaced all out of date injury reports. Management shall review all injury reports to confirm that they are documented on the correct and up to date form, and are signed by a member of management.
-If a guardian refuses to sign that will be noted and signed off by a second staff member.
-If a guardian refuses to sign that will be noted and signed off by a second staff member.
Standard 8VAC20-780-60-A
Repeat Violation / Systemic Deficiency
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all of the required elements.
1. The enrollment record for child 1 lacked a second emergency contact. The enrollment record for child 3 did not include an address for both emergency contacts and the enrollment record for child 4 lacked documentation of 2 emergency contacts.
2. The enrollment record for child 2 did not include a work phone number for either parent. No work phone number was listed for one parent of child 3.
3. Child 1 did not have any documentation of verification of age and identity.
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all of the required elements.
1. The enrollment record for child 1 lacked a second emergency contact. The enrollment record for child 3 did not include an address for both emergency contacts and the enrollment record for child 4 lacked documentation of 2 emergency contacts.
2. The enrollment record for child 2 did not include a work phone number for either parent. No work phone number was listed for one parent of child 3.
3. Child 1 did not have any documentation of verification of age and identity.
Plan of Correction: -The record for child 1 has been completed with a second emergency contact, and updated birth certificate verification. The record for child 3 has been updated to include the phone number for both parents. The record for child 3 was completed to include addresses for both emergency contacts, and work phone for both parents. The record for child 4 has been completed to include two emergency contacts.
-Moving forward Center Director will require completed files for all children before attendance.
-Moving forward Center Director will require completed files for all children before attendance.
Standard 8VAC20-780-70
Repeat Violation
Staff records shall contain all of the required elements.
There was no written documentation of a second reference check for staff 3 who has been employed for more than 30 days.
Staff records shall contain all of the required elements.
There was no written documentation of a second reference check for staff 3 who has been employed for more than 30 days.
Plan of Correction: -A second reference has been added to staff 3's file.
-Moving forward Center Director will have 2 references on file for all staff before they start.
-Moving forward Center Director will have 2 references on file for all staff before they start.