VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lighthouse Worship Center of Gloucester, Inc
7613 Hospital Drive
Gloucester, VA 23061
(804) 684-0713

VDSS Contact: Cassie Anderson-Leichty (757) 409-4668

Inspection Date: Feb. 13, 2024

Complaint Related: No

Areas Reviewed:

22.1 Background Checks Code 63.2 Child abuse and neglect 8VAC20-790 Introduction 8VAC20-790 Administration 8VAC20-790 General Qualifications 8VAC20-790 Building or Home Maintenance 8VAC20-790 Supervision and Ratio Requirements 8VAC20-790 Programs 8VAC20-790 Special Care Provisions & Emergencies 8VAC20-790 Special Services

Comments:

An initial subsidy health and safety (SHSI) inspection was initiated and concluded on 2/13/2024. There were 15 children present with 4 staff supervising and 1 administrator. The children were observed during free play in the classrooms, clean up time, and combined play time in the playroom. A total of 5 child records & 5 staff records were reviewed. The inspection started at 9:30 am and concluded at 11:15 am. 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.

Violations:

Standard #:	22.1-289.035-B-4
Description:	Based on record review and staff interview the center did not ensure to obtain a copy of the results of 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: Staff #5 (date of hire 9/18/2023) indicated on the sworn statement as to having lived outside of the state of Virginia within the last five years. The staff person in charge confirmed that the center had not obtained documentation of an out of state (Missouri) child abuse and neglect search.
Plan of Correction:	Action Steps: 1. The staff member has been placed on leave pending approval of the VA and MO Central Registry. 2. Moving forward the new process for ensuring all background checks are completed within the required time frame is as follows. a. During the interview process, the Virginia Central Registry will be completed, signed and held until the FBI Screening is completed. i. When the FBI Screening comes back eligible, the Virginia Central Registry will be submitted. 1. Currently, candidates come back in after FBI Screening to fill out paperwork. b. We have compiled all the necessary paperwork from all states for both Criminal Background (if not an NFF state) and Child Abuse and Neglect Registry Check/Interstate Background Check with instructions on how to process in a binder kept in the HR office. c. The sworn statement is completed during the interview. i. The new process will be - 1. HR will review: Have you lived outside of Virginia in the past five years? 2. If yes, HR will pull the necessary paperwork and have the candidate complete. 3. When the FBI Screening is returned with candidate eligible, all other required paperwork will be submitted.
Standard #:	8VAC20-770-40-D-2
Description:	Based on record review and staff interview, the center did not ensure that a prospective employee, volunteer, or any other person who is expected to be alone with one or more children enrolled in the religious exempt child day center shall undergo a search of the central registry within 30 days of employment or commencement of service. Evidence: The Director confirmed that Staff #5 (date of hire 9/18/2023) did not have documentation of a search of the central registry and has been employed in a supervisory capacity more than 30 days.
Plan of Correction:	Action Steps: 1. The staff member has been placed on leave pending approval of the VA and MO Central Registry. 2. Moving forward the new process for ensuring all background checks are completed within the required time frame is as follows. a. During the interview process, the Virginia Central Registry will be completed, signed and held until the FBI Screening is completed. i. When the FBI Screening comes back eligible, the Virginia Central Registry will be submitted. 1. Currently, candidates come back in after FBI Screening to fill out paperwork. b. We have compiled all the necessary paperwork from all states for both Criminal Background (if not an NFF state) and Child Abuse and Neglect Registry Check/Interstate Background Check with instructions on how to process in a binder kept in the HR office. c. The sworn statement is completed during the interview. i. The new process will be - 1. HR will review: Have you lived outside of Virginia in the past five years? 2. If yes, HR will pull the necessary paperwork and have the candidate complete. 3. When the FBI Screening is returned with candidate eligible, all other required paperwork will be submitted.
Standard #:	8VAC20-790-540-B
Description:	Based on document review and staff interview the center did not ensure children's records contain all that is required. Evidence: The director confirmed that the records for Child #1 and Child #2 did not have documentation of proof of their identity and age.
Plan of Correction:	Have families provide documentation needed before the children return.