Current Inspector:
Susan Ellington-Sconiers
(804) 588-2368
Inspection Date:
Feb. 28, 2023
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. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect
Comments:
A monitoring inspection was conducted on 02/28/2023 from approximately 10:09 a.m. to 4:45 p.m. There were 139 children present ranging from 4 months old to 5 years old and 22 staff supervising. The inspectors reviewed compliance in the areas of administration, qualifications and training, physical plant, staffing and supervision, programming, medication, special care and emergencies, and nutrition. Ten child (10) records and thirty-two (32) staff records were reviewed. The information gathered during the inspection determined a violation with applicable standards or law. A violation notice was issued. 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, 03/15/2023. Please specify how the deficient practice will be or has been corrected. Your plan of correction should 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 preventive measure(s). If you have any questions related to this inspection, please contact Inspector Susan Ellington-Sconiers, at 804-588-2368 or susan.ellington-sconiers@doe.virginia.gov.
Based on staff record review, the provider failed to ensure that four of thirty-two staff records contained a criminal record check prior to the first day of employment. Evidence: The record for S5, employed 12/01/2022 did not contain the results of a criminal record check prior to the first day of employment. The results were dated 01/25/2023. The record for S13, employed 12/01/2022 did not contain the results of a criminal record check prior to the first day of employment. The results were dated 01/04/2023. The record for S17, employed 12/01/2022 did not contain the results of a criminal record check prior to the first day of employment. The results were dated 12/02/2022. The record for S20, employed 12/01/2022 did not contain the results of a criminal record check prior to the first day of employment. The results were dated 12/22/2022.
Plan of Correction:
These four employees were employed and background checked under the previous owner's license, and they were not processed in time for my 12/1/2022 start date. Administration will continue to make sure that all employees are background checked before their hire date.
Standard #:
8VAC20-770-60-C-2
Description:
Based on staff record review, the provider failed to ensure that two of thirty-two staff records contained central registry findings within 30 days of employment. Evidence: The record for S17, employed 12/01/2022 did not contain the results of a central registry check. The record for S19, employed 12/01/2022 did not contain the results of a central registry check within 30 days of hire. The results were dated 01/18/2023.
Plan of Correction:
These 2 employees did have central registries under the previous owner's license. We will keep better documentation of sent central registries. The director will continue to make sure any new hires have their central registry complete within 30 days of hire.
Standard #:
8VAC20-780-160-A
Description:
Based on child record review, the provider failed to ensure that five of five records contained the required information for each child enrolled. Evidence: The records for C5, C6, and C10 did not contain the parental work phone numbers, when applicable. The record for C5 did not document the child?s first day of attendance. The records for C4 and C6 did not document allergies or any health problems of the child. The element on the form was blank. The record for S5 did not contain a written agreement between the parent and the center as required by 8VAC20-780-90; documentation of viewing proof of the child?s identity and age; and documentation of health information required by 8VAC-780-130 and 8VAC780-140. The record for S6 did not document a second emergency contact for the child.
Plan of Correction:
The director will ensure that child records are complete and that no information is missing before the child's first day of care.
Standard #:
8VAC20-780-160-A
Description:
Based on staff record review, the provider failed to ensure that 31 of 32 staff records contained information required by 8VAC20-780-160.A. Evidence: The records for S1, S3, S4, S6, S7, S8, S9, S11, S12, S15, S16, S17, S18, S19, S20, S21, S22, S24, S25, S26, S28, S29, S30, S31, and S32 employed 12/1/2022 did not document a tuberculosis (TB) screening being submitted at the time of employment and prior to coming into contact with children. The screenings were completed 12/07/2022. The record for S5, employed 12/01/2022 did not contain the results of a TB screening. The record for S10, employed 01/10/2023 did not document a tuberculosis (TB) screening within the required time frame. The screening completed 11/17/2022 was more than 30 days old. The record for S13, employed 12/01/2022 did not document a TB screening being submitted at the time of employment and prior to coming into contact with children. The screening was completed 01/11/2023. The record for S14, employed 12/01/2022 did not document a TB screening being submitted at the time of employment and prior to coming into contact with children. The screening was completed 12/23/2022. The record for S23, employed 12/01/2022 did not document a TB screening being submitted at the time of employment and prior to coming into contact with children. The screening was completed 12/12/2022.
Plan of Correction:
All of these employees had previous clear TB screening results under the previous owner's license. Director has been retrained on the TB standards for any future new hires.
Standard #:
8VAC20-780-70
Description:
Based on record review, the provider did not ensure staff records were kept for four of thirty-two staff. Evidence: The record for S1, employed 12/01/2022 did not document the educational requirement of a high school program completion or the equivalent to serve as a program leader. The record for S11, employed 12/01/2022 did not document: a second employment reference; information about any health problems that may interfere with fulfilling the job responsibilities; and emergency contacts. The record for S16, employed 02/14/2023 did not document two employment references. The record for S28, employed 12/01/2022 did not document a second employment reference.
Plan of Correction:
The missing information will be obtained and added to the employee files. These 4 employees' information was in their file under the previous owner's license, but were not updated under my license.
Standard #:
8VAC20-780-245-L
Description:
Based on interview with program director, the provider failed to ensure that there shall be at least one staff member on duty who has obtained within the last three years instruction in performing a daily health observation of children. Evidence: The program director confirmed that no staff person is currently certified to perform the daily health observation of children.
Plan of Correction:
The program director scheduled the daily health observation class as soon as this was brought to our attention with the inspector. She has now already completed it.
Standard #:
8VAC20-780-270-A
Description:
Based on observation, the provider did not ensure that all areas and equipment of the center, inside and the center be maintained in a safe condition. Evidence: Plastic floor play mats in the Tugboat Room are cracked preventing adequate sanitizing. The metal bathroom stall divider in the Racer Room boy?s bathroom is rusted on the bottom near the children?s commode. Diaper pad in the Playful Planes room was cracked preventing adequate sanitizing. Plastic sofa pillows in Classroom 8 are cracked preventing adequate sanitizing.
Plan of Correction:
New mats will be purchased to replace the old ones that have wear on the corners. Bathroom stall divider will be fixed and/or divider will be replaced. New diaper changing pad has already been replaced. New couch cushions will be purchased to replace the old ones that have wear on the corners.
Standard #:
8VAC20-780-550-G
Description:
Based on review of emergency evacuation drill documentation, the provider failed to ensure the documentation contained all the required information. Evidence: The emergency and shelter in place drill documentation dated December 2022 and January 2023 did not document: the method used for notification of the drill; the number of staff participating in the drills; any special conditions simulated; problems encountered, if any; and weather conditions.
Plan of Correction:
The director is now aware there is a newer state form and that the Goddard form we were using did not contain all of the necessary information about our drills even though we are doing the drills as directed. The new form has already been printed and is in use.
Standard #:
8VAC20-780-570-A
Description:
Based on observation, the provider failed to assure children placed in an infant feeding table were placed in protective belts and fastened securely. Evidence: Three children in the infant room were observed seated in the feeding table and the protective belts were not fastened.
Plan of Correction:
Infant room teachers have been retrained on correct procedures when cleaning children up from the tables.
Standard #:
8VAC20-780-570-E
Description:
dated for each child. Evidence: Individual infant bottles observed in the infant room refrigerated were not clearly labeled with the children?s names and date.
Plan of Correction:
We have communicated this standard with parents and teachers have been retrained on checking for this information upon child arrival.
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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