VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Callahan Learning Center
916 Maple Grove Drive
Fredericksburg, VA 22407
(540) 750-4331

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: Feb. 7, 2022 , Feb. 8, 2022 and Feb. 10, 2022

Complaint Related: Yes

Areas Reviewed:

8VAC20-780 Special care provisions and emergencies.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contact, documentation review, and interviews. An unannounced complaint investigation was initiated on 2/7/22 and completed on 2/10/22 in response to a complaint received in the licensing office regarding allegations that the center was not conducting the required monthly evacuation drills or shelter in place drills twice per year. Documentation was reviewed and interviews were conducted. The information gathered during the investigation supports the allegations and they were determined to be valid. If you have questions regarding this inspection, please contact the Licensing Inspector, Laura Brindle, at laura.brindle@doe.virginia.gov or 540-905-2062.

Violations:

Standard #:	8VAC20-780-550-D
Complaint related:	Yes
Description:	Based on interview and review of documentation, the center did not ensure that monthly evacuation drills were practiced as required. Evidence: 1. An evacuation drill was documented on 11/19/21 at 10:00am with 11 staff participating. Timesheets showed that on 11/19/21 at 10:00am there were nine staff present with the director. Seven of the nine staff who were present were interviewed and two staff reported not participating in a drill since around the Summer and two reported that they did not believe they have participated in a monthly drill since they were hired. 2. An evacuation drill was documented on 12/14/21 at 7:40am with 12 staff participating. Timesheets showed that on 12/14/21 at 7:40am there were four staff present with the director. The four staff who were present were interviewed and two reported not participating in a monthly drill since around the Summer.
Plan of Correction:	All staff have been retrained of the fire drill procedures including recognition of what the drill sound is and where to go within the primary and secondary escape routes. Training procedures have been updated to require a fire drill is done within 14 days of a new hire and that all staff have participated in a fire drill monthly regardless of absences and staff schedules. Administration will also only count staff members that are currently clocked in at the time of drill and require initials of all staff who were not clocked in at the time of the fire drill that were in the center at the time of the fire drill.
Standard #:	8VAC20-780-550-E
Complaint related:	Yes
Description:	Based on interview and review of documentation, the center did not ensure that shelter in place procedures were practiced as required. Evidence: The most recent shelter in place drill was documented on December 10, 2021 at 2:40pm with 11 staff participating. Timesheets showed that on December 10, 2021 at 2:40pm, eight staff were present with the director. Seven of the eight staff were interviewed and six report that they have not participated in a shelter in place drill since they were hired.
Plan of Correction:	All staff have been retrained of the shelter in place procedures including recognition of what the drill notification method is and where to go within the building and where to go when on the playgrounds for all shelter in place drills. Training procedures have been updated to require a shelter in place drill is done within 14 days of a new hire and that all staff have participated in a shelter in place drill regardless of absences and staff schedules, in the 6-month time period required for all shelter in place drills. Administration will also only count staff members that are currently clocked in at the time of the shelter in place drill and require initials of all staff who were not clocked in at the time of the fire drill that were in the center at the time of the shelter in place drill.