VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Reformation Lutheran Church
9283 N. Congress Street
New market, VA 22844
(540) 740-3239

VDSS Contact: Stephanie Reed (540) 272-6558

Inspection Date: Nov. 6, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-191 Background Checks for Child Welfare Agencies 63.2 Child Abuse & Neglect 63.2(17) License & Registration Procedures

Technical Assistance:

63.2-1809-A. Upon enrollment of a child in a regulated child day program, such child day program shall require information from the person enrolling the child regarding previous child day care and schools attended by the child. The regulated child day program shall also require that the person enrolling the child present the regulated child day program with the proof of the child's identity and age. The proof of identity, if reproduced or retained by the child day program or both, shall be destroyed upon the conclusion of the requisite period of retention. The procedures for the disposal, physical destruction or other disposition of the proof of identity containing social security numbers shall include all reasonable steps to destroy such documents by (i) shredding, (ii) erasing, or (iii) otherwise modifying the social security numbers in those records to make them unreadable or indecipherable by any means. B. For purposes of this section: "Proof of identity" means a certified copy of a birth certificate or other reliable proof of the child's identity and age. "Regulated child day program" is one in which a person or organization has agreed to assume responsibility for the supervision, protection, and well-being of a child under the age of 13 for less than a 24-hour period that is licensed pursuant to ? 63.2-1701, voluntarily registered pursuant to ? 63.2-1704, certified as a preschool or nursery school program pursuant to ? 63.2-1717, exempted from licensure as a child day center operated by a religious institution pursuant to ? 63.2-1716, or approved as a family day home by a licensed family day system.

Comments:

An unannounced monitoring inspection was conducted on 11/6/19 from 10:30 am until 1:05 pm at Reformation Lutheran Church to review the religious exempt requirements. At the time of the inspection 11 children were present with two staff. The sample size consisted of five children's records and three staff's records. Children and staff were observed during hand washing, snack, outdoor play, departure, circle time, free play, transitions and behavioral management. Violations were found during this inspection and can be found on the violation notice. If you have questions or concerns contact the licensing inspector at (540) 848-4123 for further assistance.

Violations:

Standard #:	22VAC40-191-40-D-2
Description:	Based on record review and interview, the center failed to have staff sign a sworn disclosure statement prior to the first day of employment and have a completed central registry record check by the end of the 30th day of employment. Evidence: 1. The records of the two staff and the substitute were reviewed. None of the three staff have a sworn disclosure statement or a completed central registry record check. The start dates for the staff are as follows: Staff 1 start date 2017; Staff 2 start date 2017; Staff 3 start date 2018. 2. The administrator verified none of the staff completed a sworn disclosure statement or completed a central registry record check.
Plan of Correction:	The three staff will be required to complete a sworn statement within 10 business days and provide the completed paperwork to be mailed within 10 business days for the central registry check. In the future all new staff will be required to complete the sworn statement and paperwork for the central registry search with the application and the central registry will be mailed upon hire.
Standard #:	63.2(17)-1716-A
Description:	Based on observations and interview, the center failed to post the fact that the center is exempt from licensure in a visible location on the premises. Evidence: 1. A tour of the facility was conducted. No posting of the center's exemption status was found. 2. The director verified they do not have the fact the center is exempt from licensure posted.
Plan of Correction:	A statement of the exemption status will be posted.
Standard #:	63.2(17)-1716-A-4
Description:	Based on record review and interview, the center failed to ensure all staff have been certified by a practicing physician or physician assistant to be free from any disability which would prevent him/her from caring for children under his/her supervision prior to start date and updated every year. Evidence: 1. The records of the two staff and the substitute were reviewed. The substitute has been employed since 2018. The file did not contain a staff health report. 2. The director stated they do not require substitutes to obtain a staff health report. The substitute is used for ratio purposes.
Plan of Correction:	The substitute will be required to provide a staff health report. In the future all staff and substitutes will be required to obtain a staff health report prior to working with children and yearly there after.
Standard #:	63.2(17)-1716-B-3
Description:	Based on record review and interview, the center failed to establish and implement a procedure in which a daily health screening and exclusion of sick children by a person trained to perform such a screening is conducted daily. Evidence: 1. The records of the three staff were reviewed. There was no documentation of completing training in daily health screening. 2. The parent handbook documented the center's sick child exclusion policy. 3. The director stated they do not have anyone that has been formally trained in daily health screening. All staff have worked with children for many years and check children daily based on their experience.
Plan of Correction:	At least one staff member will complete training in daily simple health screening. The center's procedure will be that at least one staff will be present at all times that has completed training in daily health screening.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on record review and interview, the center failed to obtain fingerprint-based criminal history check determination letters prior to the first day of employment for staff hired after 1/22/18 and by 9/30/18 for staff hired prior to 1/22/18. Evidence: 1. The records of all three staff were reviewed. Staff 1 and staff 2 were hired in 2017 and staff 3 was hired 10/18. There are no fingerprint-based criminal history check determination letters for the three staff. 2. The administrator verified they do not have fingerprint-based criminal history check determination letters for any of the three staff.
Plan of Correction:	Fingerprint-based criminal history checks will be completed for all three staff within 10 days. In the future no staff will be hired until a fingerprint-based criminal history check determination letter is obtained.