VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Orange County Government - Office on Youth (Lightfoot)
11360 Zachary Taylor Highway
Unionville, VA 22567
(540) 854-6184

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: Sept. 14, 2022

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) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced monitoring inspection was conducted on-site September 14, 2022 and concluded remotely on September 21, 2022. Staff was available during the inspection. There were 15 children present 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 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. 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 preventative measures. Please do not use staff names; list staff by positions only.

Violations:

Standard #:	8VAC20-770-60-B
Description:	Based on a review of staff records on September 20, 2022, the center failed to obtain a sworn statement from each staff prior to employment. Evidence: 1. The record of staff #1, hired 8/15/22, contained documentation of a sworn statement dated 8/17/22. 2. The record of staff #2, hired 8/22/22, contained documentation of a sworn statement dated 8/23/22.
Plan of Correction:	Site Managers will ensure this is completed and turned in during the staff orientation which is done on, or prior to, the first day on site with the children.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of staff records and interview on September 20, 2022, the center failed to ensure that each staff record contained a central registry finding within 30 days of employment. Evidence: 1. The record of staff #1, hired 8/15/22, did not contain documentation of a central registry finding. 2. Staff #3 confirmed the central registry check was not completed.
Plan of Correction:	Staff will ensure this paperwork is completed on the proper time frame moving forward.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of children's records on September 14, 2022, the center failed to ensure that each child's record contained the required information. Evidence: 1. The record of child #1, enrolled 8/10/22, did not contain documentation of the following: the name, address, and phone number of two designated people to contact in an emergency if a parent cannot be reached; the work phone number and place of employment of each parent who has custody; and previous child day care and schools attended by the child. 2. The record of child #2, enrolled 8/25/22, did not contain documentation of previous child day care and schools attended by the child. 3. The record of child #5, enrolled 8/24/22, did not contain documentation of previous child day care and schools attended by the child
Plan of Correction:	The Site Manager will work with the parents to collect the required information for the children's files.
Standard #:	8VAC20-780-70
Description:	Based on a review of staff records and interview on September 14, 2022, the center failed to ensure that staff records were kept for each staff person. Evidence: 1. The name, address, verification of age requirement, job title, and date of employment; and name, address, and telephone number of a person to be notified in an emergency, and information about any health problems that may interfere with fulfilling the job responsibilities were not kept at the center for staff #1 and staff #2. Staff #1 confirmed the information was not at the center. 2. The record of staff #1, hired 8/15/22, did not contain documentation to demonstrate that the individual possessed the education, certification, and experience required of a program leader. Staff #1 was working in the capacity of program leader during the inspection. Staff #3 confirmed that the documentation for program leader qualifications were not present in the record.
Plan of Correction:	The Site manager will review with all staff where the emergency contact forms for all staff are kept in the event of an emergency. Additionally, the emergency contact form for staff will be updated to add pertinent information that needs to be on-site while all other staff records will be maintained at the Office on Youth. Management will ensure all appropriate documentation is received prior to the start date for any supervisory staff.
Standard #:	8VAC20-780-245-L
Description:	Based on a review of staff records on September 20, 2022 and interview on September 14, 2022, the center failed to ensure there shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children. Evidence: The record of staff #1 did not contain documentation of instruction in performing the daily health observation of children. Staff #1 stated she did not complete the daily health observation training.
Plan of Correction:	Site Managers will ensure staff complete the required training to be on site. Additionally, care will be given when the weekly schedule is made to ensure all staff requirements are met.
Standard #:	8VAC20-780-340-C
Description:	Based on a review of staff records, observation, and interview, the center failed to ensure that during the stated hours of operation, there always shall be on the premises and on field trips when one or more children are present one staff member who meets the qualifications of a program leader or program director and an immediately available staff member, volunteer or other employee who is at least 16 years of age. Evidence: 1. During the inspection, staff #1 was working in the capacity of program leader with one assistant and 15 children in care. 2. The record of staff #1 does not contain documentation of program leader qualifications. 3. Staff #3 confirmed the center did not have the documentation of program leader qualifications for staff #1. Staff #3 acknowledged that staff #1 doesn't qualify as a program leader.
Plan of Correction:	Management will ensure all appropriate documentation is received prior to the start date for any supervisory staff. The staff member in question was changed to a Teacher Assistant position immediately until she could produce the requested documentation. At the time of this form being completed (09/30) the documents had not been received the staff member had given her notice and is no longer with the program.
Standard #:	8VAC20-780-500-A
Description:	Based on an interview with staff on September 14, 2022, the center failed to ensure that children wash their hands with soap and running water or disposable wipes after eating meals or snacks. Evidence: Staff #2 stated children don't wash their hands after snack. Staff #2 stated that children eat snacks and then move onto their next activity without washing their hands.
Plan of Correction:	The Site Manager will review the expectations with the staff to ensure these requirements continue to be met daily.
Standard #:	8VAC20-780-560-J
Description:	Based on a staff interview on September 14, 2022, the center failed to ensure tables are sanitized before and after each use for feeding. Evidence: Staff #1 stated that tables are not always sanitized after snack and that children move onto other activities at the tables after eating.
Plan of Correction:	The Site Manager will review the expectations with the staff to ensure these requirements continue to be met daily.