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Trisha Shanholtz
120 Refuge Church Road
Stephens city, VA 22655
(540) 327-3603

Current Inspector: Beth Orebaugh (540) 847-9173

Inspection Date: Sept. 14, 2023

Complaint Related: No

Areas Reviewed:
8VAC20-800 Administration
8VAC20-800 Personnel
8VAC20-800 Household Members
8VAC20-800 Physical Health of Caregivers and Household members
8VAC20-800 Caregiver Training
8VAC20-800 Physical Equipment and Environment
8VAC20-800 Care of Children
8VAC20-800 Preventing the Spread of Disease
8VAC20-800 Medication Administration
8VAC20-800 Emergencies
8VAC20-800 Nutrition
8VAC20-800 Transportation
8VAC20-800 Nighttime Care
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
54.1 Provider must be MAT certified to administer prescription medication.

Comments:
A monitoring inspection was initiated on 09/14/2023 and concluded on 09/14/2023. There were 5 children present, ranging in ages from 1 years to 4 years, with 2 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 5 child records and 2 staff records were reviewed.

Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the facility.

Violations:
Standard #: 8VAC20-800-800-B
Description: Based on review of documents, the provider did not ensure the emergency plan at least annually be reviewed, updated, and documented in writing each review and update to the emergency plan.

Evidence:
1. The emergency plan had not been updated or documented that it had been updated since 2019.
2. The provider confirmed that it has not been reviewed or updated since 2019.

Plan of Correction: I will be sure to do that later today and then annually. I will also be sure to document the information of when reviewed and updated.

Standard #: 8VAC20-800-680-A
Description: Based on observation, the provider did not ensure that all caregivers washed their hands with liquid soap and warm running water after diapering a child.

Evidence:
1. LI observed Staff 2 conduct a diaper change and Staff 2 did not wash their hands after the diaper change was completed.

Plan of Correction: I will retrain on diapering and make sure we do all the steps.

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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