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: Oct. 28, 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(17) License & Registration Procedures

Comments:

An unannounced monitoring inspection was completed on 10/28/2019 from 11:05 A.M. until 3:30 P.M. At the time of the inspection 24 children were in care with seven staff 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 literacy activities, music and movement, handwashing, lunchtime, transition to nap, departure of half day students, arrival of afterschool, and afternoon snacktime. 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 #:	22VAC40-185-320-B
Description:	Based on measurement, the center failed to ensure that water temperature for handwashing was below 120 degrees. Evidence: In the Girl's Restroom in the Academy near the office the water temperature measured 121.8 degrees. This bathroom is used by Classroom #1.
Plan of Correction:	Staff will place a work order with maintenance for a request for the water temperature to be lowered below 120 degrees. Staff will monitor the water temperature in the restroom.
Standard #:	22VAC40-185-510-E
Description:	Based on review of medications, the center failed to ensure all required information was labeled on over the counter emergency medications. Evidence: 1. Child 1M had a bottle of Benadryl that did not have the dosage amount written on the medication or the medication box. 2. Staff verified that the dosage amount was not labeled on the medication or the medication box.
Plan of Correction:	Staff will write the dosage amount on the box or medication bottle
Standard #:	22VAC40-191-60-B
Description:	Based on review of staff records, the center failed to obtain a signed sworn statement or affirmation before the first day of employment. Evidence: 1. Staff #2's sworn statement or affirmation was dated 09/19/2019. Date of employment was 08/26/2019. 2. Staff verified that the sworn statement was not signed until 09/19/2019, and date of employment was 08/26/2019
Plan of Correction:	The center will put together a job application packet that will have all required forms and a checklist with deadlines indicated. The center designates one person (preschool director) to be responsible and oversee the Preschool and Afterschool Programs employee files. The Preschool Director will be involved in the hiring process to ensure that the applicant knows clearly what forms are due before starting work in the Preschool and After School Program. The Preschool Director will monitor and follow-up on all pending paperwork. Each Preschool and After School Program will have a file with all the required paperwork with a dated checklist to ensure that all forms are in one place and monitor deadlines for renewals. This list will include: application, resume, verification of age, emergency contact, documentation of any health problems which may interfere with fulfilling job responsibilities, two or more references, background check that include a sworn disclosure, fingerprint, central registry in and out of state, resubmitted background checks as needed, documentation of orientation training, TB results, written information to verify education, certification, and experience, documentation of daily health observation training, documentation of CPR and First Aid Certification, documentation of MAT certification and documentation of training.
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. Staff #1's record did not contain a record of a central registry finding. Staff #1's first day of employment was 08/26/2019. The central registry background check was mailed out in 10/2019. 2. Staff #5's record did not contain a record of a central registry finding. Staff #5's day of employment was 08/26/2019. The central registry background check was mailed out on 10/03/2019. 3. Staff #2's central registry background was mailed out on 07/03/2019 and has not been returned.Date of hire for staff #2 is 08/26/2019. There had not been any follow-up done on the status of the central registry background check. 4. Staff verified that Staff #1 and Staff #5 files did not contain a completed central registry finding and were mailed out more than 30 days after employment. 5. Staff verified that Staff #2's central registry background check was mailed out on 07/03/2019, and there had not been any follow-up done on the status of the background check.
Plan of Correction:	The center will put together a job application packet that will have all required forms and a checklist with deadlines indicated. The center designates one person (preschool director) to be responsible and oversee the Preschool and Afterschool Programs employee files. The Preschool Director will be involved in the hiring process to ensure that the applicant knows clearly what forms are due before starting work in the Preschool and After School Program. The Preschool Director will monitor and follow-up on all pending paperwork. Each Preschool and After School Program will have a file with all the required paperwork with a dated checklist to ensure that all forms are in one place and monitor deadlines for renewals. This list will include: application, resume, verification of age, emergency contact, documentation of any health problems which may interfere with fulfilling job responsibilities, two or more references, background check that include a sworn disclosure, fingerprint, central registry in and out of state, resubmitted background checks as needed, documentation of orientation training, TB results, written information to verify education, certification, and experience, documentation of daily health observation training, documentation of CPR and First Aid Certification, documentation of MAT certification and documentation of training.
Standard #:	63.2(17)-1720.1-B-3
Description:	Based on a review of new staff background checks, it was determined that one staff member required an out of state central registry background search that was not completed. Evidence: 1. Staff #1 began employment on 08/26/2019. This staff person indicated that she resided in one state other than Virginia within the past 5 years. The required out of state central registry search request for this staff person has not been submitted. 2. Staff verified that the record check had not been submitted within the required time frame.
Plan of Correction:	The center will put together a job application packet that will have all required forms and a checklist with deadlines indicated. The center designates one person (preschool director) to be responsible and oversee the Preschool and Afterschool Programs employee files. The Preschool Director will be involved in the hiring process to ensure that the applicant knows clearly what forms are due before starting work in the Preschool and After School Program. The Preschool Director will monitor and follow-up on all pending paperwork. Each Preschool and After School Program will have a file with all the required paperwork with a dated checklist to ensure that all forms are in one place and monitor deadlines for renewals. This list will include: application, resume, verification of age, emergency contact, documentation of any health problems which may interfere with fulfilling job responsibilities, two or more references, background check that include a sworn disclosure, fingerprint, central registry in and out of state, resubmitted background checks as needed, documentation of orientation training, TB results, written information to verify education, certification, and experience, documentation of daily health observation training, documentation of CPR and First Aid Certification, documentation of MAT certification and documentation of training.