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Serkalem Nirayo
4209 Main Street
Alexandria, VA 22309
(703) 901-5052

Current Inspector: Karen Dickens (571) 423-6978

Inspection Date: March 19, 2024

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
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
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:
An unannounced monitoring inspection was conducted on 3/19/2024 at 3:59pm to 5:20pm. There were 5 children (12 points) directly supervised by 1 caregiver(s). The home, 1 caregiver record, 3 child's records, 3 household member's records, evacuation drills, emergency supplies, and policies were inspected. There were no medications on site today. Children were observed playing freely outside and inside the play room. There was an abundant supply of books, toys, and materials for the children. The home was clean and organized. Areas of non-compliance are identified in this report. If you have any questions regarding this inspection, please contact the Licensing Inspector, Keesha Minor: (keesha.minor@doe.virginia.gov) (571)596-3660.

Violations:
Standard #: 8VAC20-800-760-A-1
Description: Based on observation, the provider did not ensure that the first aid kit contained the minimum required items.
Evidence: observed that the first aid kit was missing a second triangular bandage.

Plan of Correction: I already replaced the Triangular Bandage.

Standard #: 8VAC20-800-770
Description: Based on observation, the provider did not ensure that she had a working portable battery-operated weather band radio.
Evidence: observed that the provider could not get the portable batter-operated weather band radio to function during the licensing inspection.

Plan of Correction: I correction the portable battery by charging it and getting a well operated weather band radio.

Standard #: 8VAC20-800-830-A
Description: Based on review, the provider did not ensure that emergency evacuation procedures are practiced monthly.
Evidence: reviewed the provider's emergency evacuation drill log and found that there was no drill practiced in February 2024.

Plan of Correction: I realized the mistake and have already done the log for March.

Standard #: 8VAC20-800-830-B
Description: Based on review, the provider did not ensure that shelter-in-place procedures were practiced a minimum of twice per year.
Evidence: reviewed the shelter-in-place drill log and found that the last documented drill was conducted within the past 12 months.

Plan of Correction: I have completed the procedure more than twice a year I just didn't put it in the log but it is corrected.

Standard #: 8VAC20-800-830-C
Description: Based on review, the provider did not ensure that emergency evacuation and shelter-in-place drills were documented with the required minimum information.
Evidence: reviewed the provider's drill log and found that they did not include: 1) time it took to complete the drill, 2) number of children participating, 3) number of caregivers participating, method of notification, 4) any problems encountered, and 5) weather.

Plan of Correction: I corrected the drill log and made sure the 5 points of evidence were taken care of.

Standard #: 8VAC20-800-60-B
Description: Based on review, the provider did not ensure that they maintained children's records with the required minimum information.
Evidence: reviewed 3 children's records and found that:
1) child 2 and 3 did not have documentation of an address for either of their emergency contacts,
2) child 2 did not have documentation of medical insurance and a policy number,
3) child 2 and 3 did not have documentation of limited liability declaration or emergency preparedness plan reviewed by the parents.

Plan of Correction: I have corrected the 3 children emergency contact information by getting the parents address and the medical insurance and a policy number for child 2. For both child 2 and 3, limited liability declaration or emergency preparedness plan reviewed by the parents.

Standard #: 8VAC20-800-170-A
Description: Based on review, the provider did not ensure that they obtained from each adult household member a current report of tuberculosis screening.
Evidence: reviewed the provider's records and found that household member 1 did not have documentation of a TB screening.

Plan of Correction: (Household Member 1) is 19 years old but (they do) not live with me (they) live in New York in college but (they) will do (their) TB test shortly.

Standard #: 8VAC20-800-320-B
Description: Based on observation, the provider did not ensure that child-resistant protective covers were installed on al unused electrical outlets.
Evidence: observed 1 uncovered electrical outlet, accessible to children in the bathroom.

Plan of Correction: I corrected all of the uncovered electrical outlets starting with the outlet in the bathroom.

Disclaimer:

A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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