Inspection · 2024-02-27
Date
2024-02-27
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.
780 Special Care Provisions and Emergencies
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-770 Background Checks (8VAC20-770)
22 Checks Code, Carbon Monoxide
Inspector Notes
An unannounced monitoring inspection was initiated on 02/27/2024 ( 9:41 am - 2:25 pm) and concluded on 03/01/2024 ( 12:49 pm - 1:35 pm).
At the time of classroom review, on 02/27/2024, 67 children were present with 11 staff supervising. The children in care ranged in age from 4 months - 5 years. Children were observed during morning program time which included outdoor play. Records were reviewed for four staff and five children.
The inspector returned on 03/01/2024 to complete a review of four staff records.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were reviewed with the program director at the exit interview. The violations are documented on the violation notice issued to the facility.
Violations
16Standard 22.1-289.011-F
Based on observation and interview, the center failed to ensure that the findings of the most recent inspection shall be posted in a conspicuous place on the licensed premises.
Evidence:
1. The findings from the most recent inspection, conducted on 09/05/2023, were not posted.
a. The findings from the 07/23/2023 were posted.
2. The program director confirmed that the findings from the 09/05/2023 monitoring inspection were not posted.
Evidence:
1. The findings from the most recent inspection, conducted on 09/05/2023, were not posted.
a. The findings from the 07/23/2023 were posted.
2. The program director confirmed that the findings from the 09/05/2023 monitoring inspection were not posted.
Plan of Correction: Licensing Inspection has since been posted. Center Director will ensure we remain in compliance by making sure most recent inspection is posted within 24 hours of receiving the results.
Standard 8VAC20-770-60-C-2
Based on record review and interview, the center failed to obtain a central registry finding within 30 days of employment for staff.
Evidence:
1. Staff 2, hire date 11/13/2023, lacks the results of a central registry finding.
a. Written documentation provided indicated that the request had been returned to the facility on 01/22/2024 for additional information.
b. There was no documentation that the request had been re-submitted.
2. The program director stated she was not aware that the central registry finding was not on file nor was she aware that the request had been returned for additional information until she pulled the file for review by the inspector on 02/27/2024.
Evidence:
1. Staff 2, hire date 11/13/2023, lacks the results of a central registry finding.
a. Written documentation provided indicated that the request had been returned to the facility on 01/22/2024 for additional information.
b. There was no documentation that the request had been re-submitted.
2. The program director stated she was not aware that the central registry finding was not on file nor was she aware that the request had been returned for additional information until she pulled the file for review by the inspector on 02/27/2024.
Plan of Correction: Center Director has submitted the Central Registry for Staff 2 but it was kicked back and was requesting more information. Center Director resubmitted the Central Registry on 3/14 and will follow up and document if we have not received results by 3/30. Once we receive these results, they will be added to the employee file. Moving forward, Center Director will ensure Central Registry is submitted on the employee's first day of employment and will calendar a follow up for two weeks after their first day if we have not received the results by then.
Standard 8VAC20-780-130-A
Based on record review and interview, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Evidence:
1. Child 5, enrollment date 09/25/2023, did not have documentation of immunizations required by the State Board of Health.
a. Child 5 was in care during the inspection.
2. The program director confirmed that an immunization record was not on file for child 5.
Evidence:
1. Child 5, enrollment date 09/25/2023, did not have documentation of immunizations required by the State Board of Health.
a. Child 5 was in care during the inspection.
2. The program director confirmed that an immunization record was not on file for child 5.
Plan of Correction: Center Director has given parents until 3/30 to get current immunizations submitted to the center. If parents do not provide missing documentation, care for the child(ren) will be suspended effective 4/1 until we receive. Moving forward, Center Director will ensure all paperwork and required documentation is on file before the child's first day.
Standard 8VAC20-780-140-A
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 5, enrollment date 09/25/2023, lacked documentation of the required physical exam.
2. The program director confirmed that a physical exam was not on file for child 5.
Evidence:
1. Child 5, enrollment date 09/25/2023, lacked documentation of the required physical exam.
2. The program director confirmed that a physical exam was not on file for child 5.
Plan of Correction: Center Director has given the parents until 3/20 to get any missing documentation submitted to the center. If parents do not provide missing documentation, care for the child(ren) will be suspended effective 3/21 until we receive. Moving forward, Center Director will ensure all paperwork and required documentation is on file before the child's first day.
Standard 8VAC20-780-160-A
Based on record review and interview, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment.
Evidence:
1. Staff 3, hire date 01/02/2024, does not have documentation of a tuberculosis screening.
a. Staff 3 was present and working during the inspection.
2. Staff 4, hire date 01/15/2024, does not have documentation of a tuberculosis screening.
3. The program director confirmed that documentation of a TB screening was not available for staff 3 and staff 4.
Evidence:
1. Staff 3, hire date 01/02/2024, does not have documentation of a tuberculosis screening.
a. Staff 3 was present and working during the inspection.
2. Staff 4, hire date 01/15/2024, does not have documentation of a tuberculosis screening.
3. The program director confirmed that documentation of a TB screening was not available for staff 3 and staff 4.
Plan of Correction: Staff 3 submitted for a TB screening as of 3/15. Once we receive these results, they will be added to the employee file. Staff 4 is no longer employed. Moving forward, Center Director will ensure TB screening has been completed before the employee's first day of employment and within the last 30 days to be in compliance.
Standard 8VAC20-780-240-A
Based on record review and interview, the center failed to ensure that staff complete The Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
1. Staff 2, hire date 11/13/2023, lacks documentation of completion of The Virginia Department of Education sponsored orientation course.
2. The program director confirmed that a certificate was not on file to demonstrate that staff 2 had completed this training.
1. Staff 2, hire date 11/13/2023, lacks documentation of completion of The Virginia Department of Education sponsored orientation course.
2. The program director confirmed that a certificate was not on file to demonstrate that staff 2 had completed this training.
Plan of Correction: Completed training certificates have been printed and placed in files. Any outstanding orientation courses will be completed by 3/20 and placed in the appropriate file.
Moving forward, all certificates will be printed and placed in the file upon completion of staff orientation training.
Moving forward, all certificates will be printed and placed in the file upon completion of staff orientation training.
Standard 8VAC20-780-270-A
Based on observation, the center failed to ensure that areas and equipment of the center, inside and outside, shall be maintained in a clean and safe condition.
Evidence:
1. The bathroom between the two-year old classroom and three-year old classroom was not maintained in a clean and safe condition as demonstrated by the following:
a. Three wet pull-ups, used wipes, and crumbled toilet paper was observed on the floor of the two-year old & three- year old bathroom at approximately 10:00 am on 02/27/2024.
b. The inspector additionally observed a dry pull up, package of wipes, toilet plunger, toilet brush cleaner and a small toy were also lying on the floor near the toilet and children's hand washing sink in this bathroom. The placement of these items is a trip hazard as they are in space utilized for access to both the toilet and sink.
c. The staff in the two-year old classroom, three-year old classroom and the program director all stated they were not aware that the wet pull-ups, wipes, toilet paper and other items had been left on the floor of the bathroom.
2. There are three exposed tree roots, beside the side walk , on the infant/toddler playground. These exposed tree roots are a trip hazard.
Evidence:
1. The bathroom between the two-year old classroom and three-year old classroom was not maintained in a clean and safe condition as demonstrated by the following:
a. Three wet pull-ups, used wipes, and crumbled toilet paper was observed on the floor of the two-year old & three- year old bathroom at approximately 10:00 am on 02/27/2024.
b. The inspector additionally observed a dry pull up, package of wipes, toilet plunger, toilet brush cleaner and a small toy were also lying on the floor near the toilet and children's hand washing sink in this bathroom. The placement of these items is a trip hazard as they are in space utilized for access to both the toilet and sink.
c. The staff in the two-year old classroom, three-year old classroom and the program director all stated they were not aware that the wet pull-ups, wipes, toilet paper and other items had been left on the floor of the bathroom.
2. There are three exposed tree roots, beside the side walk , on the infant/toddler playground. These exposed tree roots are a trip hazard.
Plan of Correction: Center Director plans to address and retrain staff on the equipment and operation standards at their next Staff Meeting on 3/21. Issue addressed immediately during the inspection and brought to compliance.
Standard 8VAC20-780-290-A-3
Based on observation, the center failed to ensure that electrical outlets shall have protective covers that are of a size that cannot be swallowed by children.
Evidence:
1. One outlet in the three-year old classroom, near the large motor area, lacked a protective cover.
2. Three outlets in the two-year old class, near the bathroom, back door and front door, lacked a protective cover.
3. One outlet in the toddler classroom, near the back door, lacked a protective cover.
Evidence:
1. One outlet in the three-year old classroom, near the large motor area, lacked a protective cover.
2. Three outlets in the two-year old class, near the bathroom, back door and front door, lacked a protective cover.
3. One outlet in the toddler classroom, near the back door, lacked a protective cover.
Plan of Correction: This has since been corrected. Center Director plans to address and retrain staff on the importance of outlet covers being in place whenever the outlet is not being used at their next Staff Meeting on 3/21.
Standard 8VAC20-780-40-M
Based on classroom review and interview, the center failed to maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions documented in the allergy plan required in 8VAC20-780-60 A 8. This list shall be dated and kept confidential in each room or area where children are present.
Evidence:
1. The list of all children's allergies, sensitivities, and dietary restrictions was not maintained in the three-year old classroom.
a. The allergy list in the classroom listed, "none" however, there are children in attendance, in other classrooms, with allergies, sensitivities and dietary restrictions.
2. The allergy list in the four-year old classroom only listed allergies, sensitivities, and dietary restrictions for children in attendance for the four-year old class.
3. The program director verified that classroom allergy lists only noted allergies, sensitivities and dietary restrictions for children in the individual class rather then the entire school.
Evidence:
1. The list of all children's allergies, sensitivities, and dietary restrictions was not maintained in the three-year old classroom.
a. The allergy list in the classroom listed, "none" however, there are children in attendance, in other classrooms, with allergies, sensitivities and dietary restrictions.
2. The allergy list in the four-year old classroom only listed allergies, sensitivities, and dietary restrictions for children in attendance for the four-year old class.
3. The program director verified that classroom allergy lists only noted allergies, sensitivities and dietary restrictions for children in the individual class rather then the entire school.
Plan of Correction: Allergy lists have been made current, are posted and include all applicable children enrolled at the center. Moving forward the list will be checked and updated on the 15th of every month to ensure compliance.
Standard 8VAC20-780-500-B
Based on observation, the center failed to ensure that when diapering of children disposable diapers shall be disposed in a leakproof or plastic-lined storage system that is either foot -operated and that the diapering surface shall be sanitized after each use for diapering.
"Sanitized" means the surface of the item is sprayed or dipped into the disinfectant solution and allowed to air dry on the surface for a minimum of two minutes or according to the disinfectant solution instructions.
Evidence:
1. The surface of the diaper changing table, in the two-year old classroom, was not allowed to air dry after two diaper changes on 02/27/2024 at approximately 10:10 am.
a. The surface was immediately wiped with a wet wipe after the disinfectant was sprayed.
2. Three wet disposable pull-ups were observed on the floor of the bathroom located between the two-year old and three-year old classroom on 02/27/2024 at approximately 10:00 am.
"Sanitized" means the surface of the item is sprayed or dipped into the disinfectant solution and allowed to air dry on the surface for a minimum of two minutes or according to the disinfectant solution instructions.
Evidence:
1. The surface of the diaper changing table, in the two-year old classroom, was not allowed to air dry after two diaper changes on 02/27/2024 at approximately 10:10 am.
a. The surface was immediately wiped with a wet wipe after the disinfectant was sprayed.
2. Three wet disposable pull-ups were observed on the floor of the bathroom located between the two-year old and three-year old classroom on 02/27/2024 at approximately 10:00 am.
Plan of Correction: Center Director plans to address and retrain staff on the Diapering Procedure and Sanitization standards at their next Staff Meeting on 3/21.
Standard 8VAC20-780-570-C
Based on record review and interview, the center failed to ensure that the record of each child on formula shall contain the brand of formula and the child's feeding schedule.
Evidence:
1. Written documentation of the brand of formula and feeding schedule was not available for child 1, child 2 and child 3.
a. Child 1, 2 and 3 were in care during the inspection on 02/27/2023 and are bottle fed.
2. Infant staff confirmed that a written feeding schedule and brand of formula was not on file.
Evidence:
1. Written documentation of the brand of formula and feeding schedule was not available for child 1, child 2 and child 3.
a. Child 1, 2 and 3 were in care during the inspection on 02/27/2023 and are bottle fed.
2. Infant staff confirmed that a written feeding schedule and brand of formula was not on file.
Plan of Correction: Center Director has given the parents until 3/20 to get any missing documentation submitted to the center. If parents do not provide missing documentation, care for the child(ren) will be suspended effective 3/21 until we receive. Moving forward, Center Director will ensure all paperwork and required documentation is on file before the child's first day.
Standard 8VAC20-780-580-B
Based on observation and interview, the center failed to ensure that any vehicle used by the center for the transportation of children shall meet the safety standards set by the Department of Motor Vehicles.
Evidence:
1. The facility bus used to drop off and pick up children from public school lacked a current vehicle registration. The sticker on the attached license plates indicated the registration expired August 2023.
2. The program director stated she did not have a current registration sticker or certificate for the facility bus in use during the inspection on 02/27/2024 and 03/01/2024.
Evidence:
1. The facility bus used to drop off and pick up children from public school lacked a current vehicle registration. The sticker on the attached license plates indicated the registration expired August 2023.
2. The program director stated she did not have a current registration sticker or certificate for the facility bus in use during the inspection on 02/27/2024 and 03/01/2024.
Plan of Correction: Bus has been removed from use until registration is valid. Bus maintenance company was contacted on 3/13 and is sending the up-to-date registration form.
Moving forward, a spreadsheet will be used to monitor all relevant bus information to ensure compliance.
Moving forward, a spreadsheet will be used to monitor all relevant bus information to ensure compliance.
Standard 8VAC20-780-60-A
Based on record review and interview, the center failed to ensure that children's records contain all required documents.
Evidence:
1. The enrollment record for child 1 lacked the following required information:
a. Phone number for child's physician;
b. An address for the second emergency contact.
2. The enrollment record for child 2 lacked the registration form containing all required elements.
a. The program director confirmed that a completed enrollment form was not available for child 2.
b. The program director stated that child 2 had an enrollment date of 08/03/2023.
3. The enrollment record for child 3 lacked the following required information:
a. The work phone number for each parent's place of employment;
b. An address and phone number for the second designated emergency contact.
4. The enrollment record for child 4, enrollment date 08/05/2021, lacked documentation of verification of age and identity.
5. The program director (staff 1 )confirmed the above documentation was missing from the records of child 1, 2 , 3 and 4.
Evidence:
1. The enrollment record for child 1 lacked the following required information:
a. Phone number for child's physician;
b. An address for the second emergency contact.
2. The enrollment record for child 2 lacked the registration form containing all required elements.
a. The program director confirmed that a completed enrollment form was not available for child 2.
b. The program director stated that child 2 had an enrollment date of 08/03/2023.
3. The enrollment record for child 3 lacked the following required information:
a. The work phone number for each parent's place of employment;
b. An address and phone number for the second designated emergency contact.
4. The enrollment record for child 4, enrollment date 08/05/2021, lacked documentation of verification of age and identity.
5. The program director (staff 1 )confirmed the above documentation was missing from the records of child 1, 2 , 3 and 4.
Plan of Correction: Center Director has given the parents until 3/20 to get any missing documentation submitted to the center. If parents do not provide missing documentation, care for the child(ren) will be suspended effective 3/21 until we receive it. Moving forward, Center Director will ensure all paperwork and required documentation is on file before the child's first day.
Standard 8VAC20-780-70
Based on record review and interview, the center failed to ensure that staff records contain all required elements:
Evidence:
1. The record for staff 1, hire date 04/17/2023, lacked the following required information:
a. The name, address and phone number of a person to be notified in an emergency;
b. Documentation that two or more references as to character and reputation as well as competency were checked before employment.
c. Staff 1 was present and working in the facility during the inspection.
2. The record for staff 2, hire date 11/13/2023, lacked documentation of orientation training required by 8VAC20-780-240.B .
3. The record for staff 3, hire date 01/02/2024, lacked documentation of orientation training required by 8VAC20-780-240.B.
a. The name, address and telephone number of a person to be notified in an emergency was not on file for staff 3.
b. Documentation to demonstrate that staff 3 possesses the education required by her job title of program leader was not on file.
c. Staff 3 was present and working in the facility during the inspection.
4. The record for staff 4, hire date 01/15/2024, lacked documentation of orientation training required by 8VAC20-780-240.B.
5. The program director confirmed that the above documents/documentation was not on file.
Evidence:
1. The record for staff 1, hire date 04/17/2023, lacked the following required information:
a. The name, address and phone number of a person to be notified in an emergency;
b. Documentation that two or more references as to character and reputation as well as competency were checked before employment.
c. Staff 1 was present and working in the facility during the inspection.
2. The record for staff 2, hire date 11/13/2023, lacked documentation of orientation training required by 8VAC20-780-240.B .
3. The record for staff 3, hire date 01/02/2024, lacked documentation of orientation training required by 8VAC20-780-240.B.
a. The name, address and telephone number of a person to be notified in an emergency was not on file for staff 3.
b. Documentation to demonstrate that staff 3 possesses the education required by her job title of program leader was not on file.
c. Staff 3 was present and working in the facility during the inspection.
4. The record for staff 4, hire date 01/15/2024, lacked documentation of orientation training required by 8VAC20-780-240.B.
5. The program director confirmed that the above documents/documentation was not on file.
Plan of Correction: -Completed on 3/13 (Staff 1)
-Completed on 3/20 (staff 2)
-Staff Orientation Documentation, Emergency Contact, Program Leader Qualifications for to be completed by 3/20 (Staff 3)
-Staff 4 no longer employed
Moving forward, all required documents will be collected prior to the staff members' first day.
-Completed on 3/20 (staff 2)
-Staff Orientation Documentation, Emergency Contact, Program Leader Qualifications for to be completed by 3/20 (Staff 3)
-Staff 4 no longer employed
Moving forward, all required documents will be collected prior to the staff members' first day.
Standard 8VAC20-780-90-A
Based on record review and interview, the center failed to ensure that a written agreement between the parent and the center shall be in each child's record by the first day of the child's attendance. The agreement shall be signed by the parent and shall include authorization for emergency medical care, pick up of ill child and notification of communicable disease.
Evidence:
1. The written parent agreement was not on file in the enrollment record of child 4.
2. The program director confirmed that a parent agreement was not on file for child 4.
Evidence:
1. The written parent agreement was not on file in the enrollment record of child 4.
2. The program director confirmed that a parent agreement was not on file for child 4.
Plan of Correction: Center Director has given the parents until 3/15 to get any missing documentation submitted to the center. If parents do not provide missing documentation, care for the child(ren) will be suspended effective 3/18 until we receive. Moving forward, Center Director will ensure all paperwork and required documentation is on file before the child's first day.
Standard 8VAC20-820-120-E-6
Based on observation, the center failed to ensure that a copy of any special order issued by the department shall be posted in a prominent place at each public entrance of the licensed premises to advise consumers of serious or persistent violations.
Evidence:
1. The special order issued on 11/16/2023 was not posted in a prominent place at each public entrance of the licensed premises on 02/27/2024.
2. The program director confirmed that the special order issued on 11/16/2023 was not posted.
Evidence:
1. The special order issued on 11/16/2023 was not posted in a prominent place at each public entrance of the licensed premises on 02/27/2024.
2. The program director confirmed that the special order issued on 11/16/2023 was not posted.
Plan of Correction: Special Order has since been posted. Center Director will ensure we remain in compliance by making sure the Special Order stays posted.