VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sacred Heart of Jesus Catholic Church
110-120 Keating Drive
Winchester, VA 22601
(540) 662-7177

Current Inspector: Amy Tomblin (804) 629-3923

Inspection Date: May 1, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-185 ADMINISTRATION. 22VAC40-185 STAFF QUALIFICATIONS AND TRAINING. 22VAC40-185 PHYSICAL PLANT. 22VAC40-185 STAFFING AND SUPERVISION. 22VAC40-185 PROGRAMS. 22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES. 22VAC40-185 SPECIAL SERVICES. 22VAC40-191 Background Checks (22VAC40-191) 63.2 Child Abuse & Neglect 63.2 Facilities & Programs.

Comments:

An unannounced monitoring inspection was completed on 05/01/2019 from 10:20 A.M. until 2:15 P.M. At the time of the inspection 37 children were in care with seven staff and one administrator present. Five children's records, five staff records, required posted information, evacuation drills, one medication and required documentation, health inspection, fire inspection,first aid kits, emergency supplies, and outside play area were reviewed. Children were observed during transition times to outside play time, outdoor gross motor time, handwashing, listening and coloring activity, free choice, letter recognition activity, lunchtime, handwashing, and naptime. The exceptions to compliance are noted on the violation notice. If you have questions or concerns contact the licensing inspector at (540)-430-9257 for further assistance.

Violations:

Standard #:	22VAC40-185-160-A
Description:	Based on review of staff files, the center failed to ensure that a negative tuberculosis screening/testing was completed and submitted no later than 21 days after employment. Evidence: 1. Staff #2's file did not have documentation of a tuberculosis screening/test being completed. Date of hire was February 2018. 2. Staff #4's tuberculosis screening was dated 10/12/2018. Date of hire was 09/06/2018 2. Staff verified date of hire for Staff # 2 and Staff # 4, that there was not a completed tuberculosis screening on file for Staff #2, and the date Staff #4's tuberculosis screening was completed.
Plan of Correction:	All staff were sent for a TB test or screening. We will track when TB test are required after the first day of employment to make sure they are obtained with in the 21 days of employment.
Standard #:	22VAC40-185-160-C
Description:	Based on review of staff files, the center failed to ensure that an updated tuberculosis screening was completed at least two years form the initial screening or testing. Evidence: 1. Staff #1's last documented tuberculosis screening was dated 01-03-2017. 2. Staff verified that the tuberculosis screening dated 01-03-2017 was the most current tuberculosis screening on file.
Plan of Correction:	All TB screeing/test updates were completed. We will track all staff TB dates and obtain updates before the two year expiration.
Standard #:	22VAC40-185-60-A
Description:	Based on review of children files, the center failed to obtain all required information for a child's file. Evidence: 1. Child #2's file did not contain emergency address for two of the emergency contacts. Date of enrollment was 01-07-2019. 2. Staff verified that Child #2's record did not contain the emergency address for the emergency contacts.
Plan of Correction:	Emergency contacts were obtained for the child. In the future we will make sure all registration forms have all required information.
Standard #:	22VAC40-185-70-A
Description:	Based on review of staff files, the center failed to obtain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering. Evidence: 1. The date of hire for Staff #1 was 03-06-2017. There was no documentation on file of references being completed before employment. 2. The date of hire for Staff #2 was February 2018. There was no documentation on file of references being completed before employment. 3. The date of hire for Staff #3 was 08-15-2015. There was no documentation on file of references being completed before employment.
Plan of Correction:	Missing references were obtained. In the future all reference checks will be completed before the first day of employment.
Standard #:	22VAC40-185-90--A
Description:	Based on review of children's records, the center failed to ensure that each child's record contained all required information. Evidence: 1. Child #2's file did not contain a statement that the parent will inform the center within 24 hours or the next business day after his/her child or any member of the immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately. Date of enrollment was 01-07-2019. 2. Child #2's file did not contain a statement giving authorization for medical care should an emergency occur when the parent cannot be located immediately. Date of enrollment was 01-07-2019. 3. Child #2's file did not contain a statement that the center will notify the parent when the child becomes ill and that the parent will arrange to have the child picked up as soon as possibly if so requested by the center. Date of enrollment was 01-07-2019. 2. Staff verified that the statements and written agreements were not on file for Child #2, and verified date of enrollment as 01-07-2019.
Plan of Correction:	Files were corrected. We will review all children files at the start of the school year and obtain all required information.
Standard #:	22VAC40-185-280-B
Description:	Based on observation, the center failed to ensure that all hazardous materials were kept in a locked location. Evidence: 1. On a shelf of the cubbie unit outside of the Pre-School Classroom, located in MulDowny Hall, there was a three pack of Clorox Disinfectant Wipes. 2. The warning label stated "keep out of reach of children, and hazardous to humans and animals." 3. Staff verified that the Clorox Wipes were not in a locked location and were on a shelf of the cubbie unit.
Plan of Correction:	The materials were removed from the cubbies. All staff will be reminded to do a daily walk thru there room to make sure all hazardous materials are in a locked location.
Standard #:	22VAC40-185-290-3
Description:	Based on observation, the center failed to ensure that all electrical outlets were covered with protective covers. Evidence: 1. In MulDowny Hall in the Fellowship Hall there were twelve electrical outlets that did not have protective covers. 2. In MulDowny Hall in the entrance of the girl's bathroom there was one electrical outlet that did not have a protective cover. 3. Staff verified that there were electrical outlets in MulDowny Hall and in the entrance to the girl's bathroom that did not have protective covers.
Plan of Correction:	All outlets were covered with protective covers. Administration will review that all outlet covers need to be covered in any area of the building where children are present.
Standard #:	22VAC40-191-60-C-2
Description:	Based on review of staff records, the center failed to obtain a central registry finding within 30 days of employment. Evidence: 1. The record for Staff #2 did not contain a record of a central registry finding. Staff #2's day of employment was February 2018. 2. The record for Staff #4 did not contain a record of a central registry finding. Staff #4's day of employment was 09-06-2018. 3. Staff verified that Staff #2 and Staff #4 files did not contain a completed central registry finding.
Plan of Correction:	All central registry checks have been submitted.