VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shepherd's Care Day School
728 Highland Avenue SE
Roanoke, VA 24013
(540) 342-4003

Current Inspector: Rebecca Forestier (540) 309-2835

Inspection Date: Jan. 26, 2024

Complaint Related: Yes

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 8VAC20-770 BACKGROUND CHECKS 22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE 63.2 CHILD ABUSE AND NEGLECT

Comments:

An unannounced complaint inspection was conducted on 01/26/2024 and 02/08/2024 in response to allegations received by the licensing office on 01/22/2024 in the areas of administration, forbidden actions, and special feeding needs. The investigation was conducted with an outside organization. There was a total of 54 children, 14 staff providing direct care and supervision, and various support staff present during the inspection. The inspector interviewed six staff members and one guardian. A total of 5 children?s records and 4 staff records as well as policies and procedures were reviewed during the inspection. On 01/26/2024, the inspector arrived to the center at 10:00 am and departed at 1:40 pm and on 02/08/2024, two inspectors arrived to the center at 12:15 pm and departed at 12:45 pm. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider. The complaint was determined to be valid.

Violations:

Standard #:	63.2-1509-A
Complaint related:	Yes
Description:	COMPLAINT RELATED Based on staff interviews and the review of an audio recorded interview, the center failed to ensure that the persons listed in the Code of Virginia, who, in their professional or official capacity (a person employed by a child day program), have reason to suspect that a child is an abused or neglected child, shall report the matter immediately to the local department of the county or city wherein the child resides or wherein the abuse or neglect is believed to have occurred or to the Department?s toll-free child abuse and neglect hotline. Evidence: During an interview on 01/26/2024, Staff 2 stated that approximately 2 months ago she observed Staff 4 pinch Child 2 (20 months). During an interview on 02/05/2024, Staff 4 admitted to pinching Child 2 on her side. The abuse of Child 2 was not reported to the local department or any other authority by center staff.
Plan of Correction:	A form was created to document all conversations that occur between staff and the administrative staff and the course of action will be decided upon at that time. All staff are trained on child abuse/neglect before working in the classroom.
Standard #:	8VAC20-780-40-E
Complaint related:	Yes
Description:	COMPLAINT RELATED Based on the review of required policies and procedures and interviews with staff, the center failed to maintain the operational responsibility of the licensee to ensure that the center?s activities, services, and facilities are maintained in compliance with the center?s own policies and procedures that are required by the standards. Evidence: 1. Staff interviews and the review of an audio interview confirmed that Staff 4 did not follow the center?s discipline policy. During an interview on 02/05/2024, Staff 4 admitting to pinching Child 2 (20 months), stating that they did so in response to being bitten by Child 2. The center?s discipline policy prohibits physical punishment. 2. The record for Staff 4 contained documentation of receiving this information in writing; the document was signed on 08/19/2022.
Plan of Correction:	The employee was immediately terminated.
Standard #:	8VAC20-780-340-D
Complaint related:	No
Description:	Based on record review and staff interviews, the center failed to ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader shall be regularly present. Such program leader shall supervise no more than two aides. Evidence: Staff 1, Staff 2, Staff 3, and Staff 4 were assigned to The Tiger?s Class. The record for Staff 1 contained documentation that they held the job position of a program leader. The records for Staff 2, Staff 3, and Staff 4 contained documentation that they all held the job position of a program aide. Staff 1 was supervising a total of three aides. Staff 6 confirmed that Staff 1 was the only program lead for the group of children.
Plan of Correction:	Replace staff to have 2 program leads and 2 program aids in the class. the staff are being hired.
Standard #:	8VAC20-780-350-B-1
Complaint related:	No
Description:	Based on observation and staff interviews, the center failed to maintain the required staff-to-child ratio whenever children are in care. Evidence: During the 01/26/2024 inspection, a total of 8 children and 1 staff member were observed in The Tiger?s Class during nap time. Child 6 was 14 months old. The required staff-to-child ratio for children from birth up to 16 months is 1:4. Two staff would be required for this group of children.
Plan of Correction:	Will always ensure that ratio is met.
Standard #:	8VAC20-780-410-1
Complaint related:	Yes
Description:	COMPLAINT RELATED Based on interviews with staff and the review of an audio recorded interview, the center failed to ensure that actions towards children that are forbidden by the standards (physical punishment, striking a child, roughly handling or shaking a child) were not used at the center. Evidence: During an interview on 01/26/2024, Staff 2 stated that approximately 2 months ago they observed Staff 4 pinch Child 2 (20 months). During an interview on 02/05/2024, Staff 4 admitted to pinching Child 2 (20 months), stating that they did so in response to being bitten by Child 2.
Plan of Correction:	The employee was immediately terminated.
Standard #:	8VAC20-780-570-G
Complaint related:	Yes
Description:	COMPLAINT RELATED Based on interviews with staff, the center failed to ensure that milk, formula, or breast milk shall be not heated or warmed directly in a microwave. Evidence: During an interview on 02/08/2024, Staff 7 stated that they use a microwave to heat up the refrigerated formula for Child 5 (3 months old). The following is stated on the back of the formula container ?Warning: Do not use a microwave oven to warm formula. Serious burns may occur.?
Plan of Correction:	A bottle warmer was ordered for the class. The staff were reminded to not use microwaves to heat bottles.