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St. Stephen Lutheran Church
612 Jamestown Road
Williamsburg, VA 23185
(757) 229-6688

VDSS Contact: Christine Mahan (757) 404-0568

Inspection Date: Sept. 11, 2019

Complaint Related: No

Areas Reviewed:
22VAC40-191 Background Checks for Child Welfare Agencies
63.2(17) License & Registration Procedures

Technical Assistance:
Out of State child abuse and neglect searches and daily health observation training

Comments:
An unannounced monitoring inspection was conducted on September 11, 2019 from approximately 9:30am-12:15pm. Upon arrival to the facility, there were 32 children present with five staff members. Additional staff were on site for administrative and support purposes. The children were observed participating in small group activities directed by their teachers and playing in centers. Four rooms, two restrooms, the chapel and the outdoor playground were reviewed. The center does not offer transportation.

Violations:
Standard #: 22VAC40-191-40-D-2
Description: Based on record review, in five of staff five records reviewed, the center did not ensure that staff have a sworn statement or affirmation completed before employment and a Search of the Central Registry within 30 days of employment.

Evidence: The Administrator confirmed that the following five staff records reviewed did not have documentation of a completed sworn statement or Central Registry results:
Staff #1-(hire date 2001)
Staff #2-(hire date 2012)
Staff #3-(hire date 1999)
Staff #4-(hire date 2017)
Staff #5-(hire date 2017)

Plan of Correction: We will complete the sworn statements this week and the Central Registry checks will be done as soon as I can get a notary to complete the forms. We did have completed background checks for staff, they just were not the right ones.

Standard #: 63.2(17)-1716-A
Description: Based on observation and staff interview, the center had not posted the fact that it is exempt from licensure in a visible location on the premises.

Evidence: The Administrator confirmed that the center had not posted that it was exempt from licensure in a visible location on the premises.

Plan of Correction: Administrator will frame the letter concerning the exemption from licensure and will post it within two days.

Standard #: 63.2(17)-1716-A-6
Description: Based on observation and staff interview, the center had not described in a written statement provided to the parents or guardians of the children in the center and made available to the general public all required aspects of the child day center's operations.

Evidence: The Administrator confirmed that the following information had not been provided in writing to the parents/guardians of the center and made available to the general public: physical facilities, enrollment capacity, health requirements for staff and public liability insurance

Plan of Correction: The information will be given to parents in the upcoming news letter and then added to the parent handbook for the subsequent years.

Standard #: 63.2(17)-1716-B-3
Description: Based on staff interview, the center had not established and implemented procedures to ensure that there was a person trained to perform a simple daily health screening and exclusion of sick children.

Evidence: The Administrator confirmed that there was not a person trained to perform a simple daily health screening of children.

Plan of Correction: Staff will be trained by the end of this week.

Standard #: 63.2(17)-1716-B-7
Description: Based on staff interview, the center did not ensure that there were established and implement procedures regarding reports of serious injury or death of children attending the child day center.

Evidence: The Administrator confirmed that the center had not established and implemented the following procedures:

1. Ensuring that all incidents involving serious physical injury to or death of children attending the child day center are reported to the Commissioner.

2. Reports of serious physical injuries, which shall include any physical injuries that require an emergency referral to an offsite health care professional or treatment in a hospital, shall be submitted annually.

3. Reports of deaths shall be submitted no later than one business day after the death occurred.

Plan of Correction: Administrator will disseminate the information in writing to all staff.

Standard #: 63.2(17)-1720.1-B-2
Description: Based on record review, in five of five staff records reviewed, the center did not ensure that staff submit to fingerprinting and obtain results by September 30, 2018.

Evidence: The Administrator confirmed that staff obtained fingerprint eligibility letters after September 30, 2018:
Staff #1-(hire date 2001) fingerprint results letter dated 4/8/19
Staff #2-(hire date 2012) fingerprint results letter dated 7/22/19
Staff #3-(hire date 1999) fingerprint results letter dated 7/22/19
Staff #4-(hire date 2017) fingerprint results letter dated 7/3/19
Staff #5-(hire date 2017) fingerprint results letter dated 8/8/19

Plan of Correction: There was a great deal of confusion of procedures and the timeline of obtaining fingerprint checks. Once we got the window of notification of the free checks all staff have completed this requirement.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.


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