VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lutheran Social Services of the National Capital Area
8922 Little River Turnpike
Fairfax, VA 22031
(202) 723-3000

Current Inspector: Kevin Lassiter (804) 241-2093

Inspection Date: March 13, 2023

Complaint Related: No

Areas Reviewed:

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 An on site inspection was conducted on 3/13/2023 from 10:30 am until 4:00 p.m. Number of children in care:7 Number of approved provider homes: 14 The licensing inspector completed a tour of the physical plant that included the office setting and conditions. Number of children?s records reviewed: 1 (1 URM child) Number of staff records reviewed: 4 Number of interviews conducted with staff: 1 entrance and exit interview with the Executive Director, Supervisor of URM, Director of TFC, and HR director. Observations by licensing inspector: The license was posted along with inspection documents Additional Comments/Discussion: 2 provider home records were reviewed. The evidence gathered during the inspection determined non-compliance with applicable standards or laws, and violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with the applicable standard 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 exit interview. 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 Cindy Horne, Licensing Inspector at (804) 382-3964 or by email at cynthia.horne@dss.virginia.gov

Violations:

Standard #:	22VAC40-131-180-J-2
Description:	Violation: Based on a review of two foster home records (FH-1 and FH-2), and an interview with agency representatives (AR-1 and AR-2), the agency failed to document that the homes comply with the standards for the home as required by 22VAC40-131-190. Evidence: 1) FH-1 was approved on 3/14/22. FH-2 was approved on 3/08/22. There was no documentation in their records of compliance with the home environment elements listed under 22VAC40-131-190. 2) In an exit interview on 3/13/23, AR-1 and AR-2 acknowledged that the checklist they developed regarding the home environment elements was not used with these families.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-191-40-C-1-d
Description:	Violation: Based on a review of the record of a foster home (FH-2) and an interview with agency representatives (AR-1 and AR-2), the agency failed to obtain a sworn disclosure statement for the foster father in FH-2 prior to their approval. Evidence: 1) FH-2 was approved on 3/08/22. There was no sworn statement for the foster father in the record. 2) In an exit interview on 3/13/23, AR-1 and AR-2 acknowledged that the sworn statement was not in the record as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-191-40-D-1-b
Description:	Violation: Based on a review of three personnel records (P-1, P-2, and P-3) and interviews with agency representatives (AR-1, AR, 2- and AR-4), the agency failed to obtain required background checks before 30 days of employment ended. Evidence: 1) P-1 began employment on 10/24/22. The criminal history record check was dated 1/28/23. There was no central registry search contained in the record. 2) P-2 began employment on 10/03/22. The criminal history record check was dated 1/09/23. The central registry search was dated 12/22/22. 3) P- 3 began employment on 10/03/22. The criminal history record check was dated 1/09/23. The central registry search was dated 11/06/22. 4) In an exit interview on 3/13/23, AR-1, AR-2, and AR-4 acknowledged that the background checks and central registry searches were not obtained within the required time frames.
Plan of Correction:	Not available online. Contact Inspector for more information.