VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Embrace Foster Care
6345 Center Drive
Norfolk, VA 23502
(757) 847-9385

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Nov. 16, 2022 , Nov. 17, 2022 and Nov. 18, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-131 ORGANIZATION AND ADMINISTRATION 22VAC40-131 PERSONNEL 22VAC40-131 PROVIDER HOMES 22VAC40-131 CHILDREN?S SERVICES 22VAC40-131 ADDITIONAL REQUIREMENTS FOR SPECIFIC PROGRAMS 22VAC40-191 BACKGROUND CHECKS FOR CHILD WELFARE AGENCIES

Comments:

Type of inspection: Monitoring. Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/16/2022 10:40 a.m. to 2:55 p.m., 11/17/2022 10:30 a.m. to 12:14 p.m. on-site at the Norfolk agency and 11/18/2022 1:08 p.m. to 1:30 p.m. on-site at the Fredericksburg agency to review personnel records. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The Licensing Inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 3. Number of foster homes reviewed: 4. Number of staff records reviewed: 2. Number of interviews conducted with staff: 2. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the meeting. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Connie McHale, Licensing Inspector (804) 662-7084 or connie.mchale@dss.virginia.gov.

Violations:

Standard #:	22VAC40-131-110
Description:	Violation: Based on review of the records for foster homes FH1, FH2, FH3, and FH4 and interview with agency representatives AR1 and AR2, the licensee failed to ensure all materials and information received by the licensee indicated the date received. Findings: 1. Review of several background check documents in the records did not indicate the date received. 2. AR1 and AR2 acknowledged that the date received was not indicated.
Plan of Correction:	Staff have been trained (based on other office reviews) to ensure all documents received (including Sworn Disclosures) are date stamped
Standard #:	22VAC40-131-180-G
Description:	Violation: Based on review of the record for foster home FH1 and interview with agency representatives AR1 and AR2, the licensee failed to document a minimum of three references on each applicant. Findings: 1. Two of the three required references were documented in the record. 2. The third reference was not documented. 3. AR1 and AR2 confirmed that only two of the three required references were documented in the record.
Plan of Correction:	Foster Parent Coordinators will be re-trained to ensure all foster homes have 3 reference per foster parent (unless the person doing the reference listed both foster parents).
Standard #:	22VAC40-131-180-J-2
Description:	Violation: Based on review of documents provided for foster home FH1 and interview with agency representatives AR1 and AR2, the licensee failed to include summary of content information from available information, as required by 180J.2.e. in the home study. Findings: 1. The home study for FH1 did not include the summary of content information from references, background checks, driving record, employment history, assets, resources, debts and obligations. 2. AR1 and AR2 confirmed that this summary of content information was missing from the home study. Violation: 22VAC40-131-180.J.2.f, Based on review of the record for foster home FH1 and interview with agency representatives AR1 and AR2, the home study failed to document that the foster home complies with the standards as required by 22VAC40-131-190. Findings: 1. 22VAC40-131-190-R.1. requires firearms and other weapons be unloaded and stored with the weapon?s safety mechanisms activated in a locked closet or cabinet. 2. 22VAC40-131-190.R.2. requires ammunition stored in a locked location separate from the weapon. 3. 22VAC40-131-190.R.3.requires the key or combination to the locked closet and cabinet shall at all times be maintained out of reach of children. 4. The home study for FH1 documents the firearm is locked in a safe and ammunition is locked up separately in a separate locked container. ?They are locked away in the car?. 5. AR2 provided additional information: the firearm is locked in a portable gun safe in the trunk of the car. The key is on the foster parent?s key ring. 6. The home study does not document the firearm storage complies with standard 190.R.1, the ammunition storage complies with standard 190.R.2. or that the keys are maintained out of reach of all children in the home (standard 190.R.3.) Violation: 22VAC40-131-180.J.2.f Based on review of the home study for foster home FH1 and interview with agency representatives AR1 and AR2, the licensee failed to ensure that the foster home complies with standards as required by 22VAC40-131-190. Findings: 1. 22VAC40-131-190.P requires that approved providers shall arrange for responsible adults to be available to serve in the caretaker?s role in case of emergencies. 2. The approved provider, FH1, indicated he did not have anyone who could help him with child care in case of emergencies. 3. AR1 and AR2 confirmed there was no documentation of a responsible adult or adults to be available to serve in the caretaker?s role in case of emergencies.
Plan of Correction:	The home study format has been corrected to include designated places for summary from information obtained. All staff will be re-trained on the firearm requirement for storage. The home study reviewed will have an addendum created to show where the firearm, ammunition, and keys are stored Foster Parent Coordinators will be re-trained to ensure each family certified/re-certified has a back-up provider plan in the event of an emergency.
Standard #:	22VAC40-131-370-F
Description:	Violation: Based on review of the record for foster home FH2 and interview with agency representatives AR1 and AR2, the case file was not up to date. Findings: 1. The record for FH2 did not include the medical examination and Tuberculosis (TB) screening for household member, HM1. 2. AR1 acknowledged that the medical examination and TB screening were not filed in the record. AR1 provided the documentation during the on-site inspection.
Plan of Correction:	Foster Parent Coordinator will be reminded to look for physical forms and TB test or screening for each foster parent for both certs and re-certs of foster parents.
Standard #:	22VAC40-191-50-A-1-a
Description:	Violation: Based on review of the records for foster homes FH2 and FH3 and interview with agency representatives AR1 and AR2, the sworn statements were not fully completed, as required by this standard. Findings: 1. The sworn disclosure statement completed by household member HM1 reviewed in the record for foster home FH2 did not document a response to question #5 (left blank). 2. The sworn disclosure statement completed by the foster parent in foster home FH3 did not document a response to question #5 (left blank). 3. AR1 and AR2 acknowledged that the sworn statements were incomplete.
Plan of Correction:	All staff have been re-trained on sworn disclosures and ensuring question #5 is answered
Standard #:	63.2-901.1 B
Description:	Violation: Based on review of the record for foster home FH1 and interview with agency representatives AR1 and AR2, the background check did not meet the requirements of this code section. Findings: 1. The sworn disclosure statement for household member, HM1, was not found in the record for foster home FH1. 2. AR1 and AR2 acknowledged that the sworn disclosure statement was not found in the record
Plan of Correction:	All staff have been re-trained on sworn disclosures requirements for both foster parent and other household members including biological children 18yrs and over, and that all sworn disclosures need to be uploaded in the file in a timely manner