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Henrico Police Athletic League - Pinchbeck
1275 Gaskins Road
Henrico, VA 23238
(804) 290-9687

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: May 23, 2024

Complaint Related: No

Areas Reviewed:
8VAC20-780 Administration.
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies.
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minors records
22.1 Background Checks Code, Carbon Monoxide
22.1 Early Childhood Care and Education

Comments:
An unannounced renewal inspection was initiated on 5/23/2024 and concluded on 5/28/2024. The inspector was on site on 5/23/2024 from approximately 2:51 pm-4:05 pm. There were 45 children present, ranging in ages from 5 to 12 years, with 6 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, special care and emergencies, nutrition and background checks. A total of 5 child records, 5 staff records, and 6 officer/agent records were reviewed. Staff and officer records were reviewed remotely on 5/24/2024 and 5/28/2024.

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.

Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations:
Standard #: 22.1-289.035-B-2
Description: Based on a review of five staff records and interview, the center did not ensure to obtain a fingerprint background check for one staff prior to the first date of employment as required.

Evidence:
1. The record of staff #5 (date of employment: 4/30/2024) contained an outdated background check dated 9/10/2019 from the staff's previous employment which ended on 1/25/2023.
2. Administration acknowledged that a current fingerprint background check had not been obtained prior to employment.

Plan of Correction: Staff number 5's last day of employment was due to health reasons. They were re-instated as a
substitute to fill in when needed on 4/29/2024. Steps to correct the noncompliance with the
standards: 1) Team is now aware that a rehire or re-instement must be treated as a new hire
and all background checks must be done prior to hire regardless even if the one on file is within
the 5 year period. 2) A notice was sent to both manager and staff that proof of background
processing must be submitted within 5 days or 6/6/2024. Person cannot work if they do not
comply. Criminal Background Check letter stating eligible to work was received on 5/30/2024
via email and VDSS letter was dated on 5/17/2024 and VDSS stated it was emailed on 5/20/24,
but admin could not locate it. Measures to prevent the noncompliance from occurring again:
We will not rehire or reinstate former employees until they meet state requirements for new
hires and the Staff Information Sheet is current. Person responsible for implementing each
step and/or monitoring any prevenative measures: HR Manager, Site Manager, Program
Manager.

Standard #: 8VAC20-770-60-B
Description: REPEAT VIOLATION
Based on a review of five (5) staff records and interview, the center did not ensure that one staff had a completed sworn statement prior to the first date of employment as required.

Evidence:
1. The record of staff #5 (date of employment: 4/30/2024) contained an outdated sworn statement dated 8/28/2019 from the staff's previous employment which ended on 1/25/2023.
2. Administration acknowledged that a current sworn statement was not obtained for staff #5.

Plan of Correction: Staff number 5's last day of employment was due to health reasons. They were re-instated as a
substitute to fill in when needed on 4/29/2024. Steps to correct the noncompliance with the
standards: 1) Team is now aware that a rehire or re-instement must be treated as a new hire
and the Sworn Statement for Child Day Programs must be completed on the first day of
employment. 2) A notice was sent to both manager and staff that a Sworn Statement must be
submitted within 5 days or 6/6/2024. Person cannot work if they do not comply. Staff #5
stated she sent it on 5/1/2024 via email from her local library. Administration found the email
in Spam folder. Measures to prevent the noncompliance from occurring again: We will not
rehire or reinstate former employees until they meet state requirements for new hires and the
Staff Information Sheet is current. Person responsible for implementing each step and/or
monitoring any prevenative measures: HR Manager, Site Manager, Program Manager.

Standard #: 8VAC20-780-160-A
Description: REPEAT VIOLATION

Based on a review of five staff records and interview, the center did not ensure to obtain a tuberculosis (TB) screening for one (1) staff at the time of employment and prior to coming into contact with children.

Evidence:
1. The record of staff #5 (date of employment: 4/30/24) did not contain a current TB screening that had been completed within the required time frame.
2. Administration stated that staff #5 was a rehire and they had not obtained a TB screening.

Plan of Correction: Staff number 5's last day of employment was due to health reasons/surgery. They were reinstated
as a substitute to fill in when needed on 4/29/2024. Steps to correct the
noncompliance with the standards: Team is now aware that a rehire or re-instement must be
treated as a new hire and the TB screening for Child Day Programs must be completed prior to
first day. Steps to correct the noncompliance with the standards: A notice was sent to both
manager and staff that proof of TB screening must be submitted within 5 days or 6/6/2024.
Person cannot work if they do not comply. Staff #5 was supposed to be screened at no charge
on 5/18/2024, but did not show. Arrangements were made again for staff on 6/3/24. If form is
not received by 6/5/2024, staff will be terminated. Measures to prevent the noncompliance
from occurring again: We will not rehire or reinstate former employees until they meet state
requirements for new hires and the Staff Information Sheet is current. Person responsible for
implementing each step and/or monitoring any prevenative measures: HR Manager, Site
Manager, Program Manager.

Standard #: 8VAC20-780-40-J
Description: Based on a review of documentation and interview, the center did not ensure to annually update their injury prevention procedures based on documentation of injuries and a review of the activities and services.

Evidence:
1. The center was unable to provide documentation of a 2023 or 2024 annual injury prevention plan.

Plan of Correction: Steps to correct the noncompliance with the standards: All injury information will be added
to the monthly report given to Program Manager and Executive Director. Measures to prevent
the noncompliance from occurring again: Manager training in what constitutes an injury and
regular site inspections by Program Manager.
Person responsible for implementing each step and/or monitoring any preventative measures:
Site Manager, Program Manager

Standard #: 8VAC20-780-240-A
Description: REPEAT VIOLATION

Based on a review of five staff records and interview, the center did not ensure that one staff completed the Virginia Department of Education-sponsored orientation course within 90 days of employment as required.

Evidence:
1. The record of staff #2 (date of employment: 6/12/2023) did not contain documentation of completion of the Virginia Department of Education-sponsored orientation course.
2. Administration acknowledged that it had not been completed.

Plan of Correction: Steps to correct the noncompliance with the standards: Email was sent to Staff #2 on
5/24/2024 with notice to complete mandatory online orientation within 2 weeks time.
Measures to prevent the noncompliance from occurring again: We are implementing 30-60-90
day check-in's to make certain our team is on track to succeed. Person responsible for
implementing each step and/or monitoring any prevenative measures: HR Manager, Site
Manager, Program Manager.

Standard #: 8VAC20-780-550-D
Description: REPEAT VIOLATION

Based on a review of documentation and interview, the center did not ensure to implement a monthly practice evacuation drill.

Evidence:
1. An evacuation drill was not documented in January and February of 2024.
2. Administration acknowledged that the evacuation drills had not been conducted.

Plan of Correction: Steps to correct the noncompliance with the standards: All Drills and emergency information
must be posted clearly at the site and reviewed by both Site and Program Manager. Measures
to prevent the noncompliance from occurring again: Manager training and regular site
inspections by Program Manager.
Person responsible for implementing each step and/or monitoring any preventative measures:
Site Manager, Program Manager

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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