VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Goddard School at Short Pump
12400 Three Chopt Road
Henrico, VA 23233
(804) 360-8282

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: April 26, 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) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Comments:

An unannounced monitoring inspection was initiated on 4/26/2022 and concluded on 4/28/2022. The inspector was on site on 4/26/2022 from 9:10 am-12:33 pm. There were 119 children present, ranging in ages from 4 months to 6 years, with 20 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies, nutrition and background checks. A total of 10 child records and 10 staff records were reviewed. Components of the staff records were reviewed remotely. 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. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must 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 #:	22.1-289.035-A
Description:	Based on a review of 10 staff records and interview, the center did not ensure to obtain the results of a repeat central registry for 1 staff every 5 years as required. Evidence: 1. The record of staff #9 (DOH:4/28/2005) contained a central registry dated 10/19/2016. 2. Administration acknowledged that the repeat central registry had not been received.
Plan of Correction:	The director will make sure central registry is done every 5 years.
Standard #:	22.1-289.035-B-2
Description:	Based on a review of staff staff records and interview, the center did not ensure to obtain the results of a fingerprint background check for 1 staff prior to the first date of employment as required. Evidence: 1. The record of staff #4 (DOH:1/6/2022) contained a portability approval for a fingerprint check dated after hire on 1/19/2022. 2. Administration acknowledged that the background check results were received after the first date of employment.
Plan of Correction:	The director will make sure to get fingerprints before employee starts.
Standard #:	22.1-289.035-B-4
Description:	Based on a review of 10 staff records and interview, the center did not ensure to obtain the results of an out of state sex offender background check from any state in which the individual has resided in the preceding five years prior to hire for 1 staff as required. Staff hired prior to 7/1/2020 had until 12/31/2020 to comply with the out of state background check requirements. Evidence: 1. The record of staff #7 (DOH: 8/12/2019) contained a sworn statement that indicated they had resided outside of the state within the preceding 5 years. The record did not contain and out of state sex offender check. 2. Administration acknowledged that the check was missing.
Plan of Correction:	The director will make sure to get the out of state sex offender background check from any state an employee has lived in the last 5 years.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of 10 staff records and interview, the center did not ensure to obtain documentation of a central registry background check for 2 staff within 30 days of employment as required. Evidence: 1. The record of staff #6 (DOH:9/8/2021) contained a central registry dated 12/22/2021. The record of staff #8 (DOH:10/25/2021) contained a central registry dated 12/22/2021. 2. Administration acknowledged that the background checks had not been received within the required frame.
Plan of Correction:	The director will make sure background checks will be done 30 days of employment.
Standard #:	8VAC20-780-130-A
Description:	Based on a review of 10 children's records and interview, the center did not ensure to obtain documentation that 1 child had received the immunizations required by the State Board of Health before the child's first date of enrollment. Evidence: 1. The record of child #9 (DOE:9/7/2021) contained an immunization record dated 9/10/2021. 2. Administration acknowledged that the record was received after the first date of enrollment.
Plan of Correction:	The director will make sure children do not start until immunizations are received.
Standard #:	8VAC20-780-130-E
Description:	Based on a review of 10 children's records and interview, the center did not ensure to obtain documentation of additional immunizations once every six months for children under the age of two years for 1 child as required. Evidence: 1. The record of child #2 (DOE:8/18/2021) contained one immunization record dated 8/11/2021. The record did not contain updated immunizations. 2. Administration acknowledged that updated immunizations had not been obtained.
Plan of Correction:	Director will make a chart of when children need updated immunizations.
Standard #:	8VAC20-780-140-A
Description:	Based on a review of 10 children's records and interview, the center did not ensure to obtain a physical examination by or under the direction of a physician: Before the child's attendance; or within 30 days after the first day of attendance for 1 child a required. Evidence: 1. The record of child #7 (DOE: 1/3/2022) did not contain documentation of a physical examination. 2. Administration acknowledged that the document had not been obtained.
Plan of Correction:	The director will make sure all physicals from doctor are received within 30 days of enrollment.
Standard #:	8VAC20-780-160-A-2
Description:	Based on a review of 10 staff records and interview, the center did not ensure that 1 staff had a tuberculosis (TB) screening that was completed within the last 30 calendar days of the date of employment as required. Evidence: 1. The record of staff #1 (DOH:1/17/2022) contained a TB screening dated 1/2/2021. 2. Administration acknowledged that the screening was not completed within 30 calendar days of the date of employment.
Plan of Correction:	Director will make sure employees get a TB test before hire.
Standard #:	8VAC20-780-40-M
Description:	Based on observation and interview, the center did not ensure to maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions documented in the allergy plan required in 8VAC20-780-60 A 8. This list shall be dated and kept confidential in each room or area where children are present. Evidence: 1. A current dated list of children with diagnosed allergies was not observed in each room where children were present. Administration identified children in care with diagnosed food allergies. 2. Administration acknowledged that a current dated list was not kept in each room.
Plan of Correction:	The director will make sure a list of allergies are posted inside the teacher cabinet.
Standard #:	8VAC20-780-240-A
Description:	Based on a review of 10 staff records and interview, the center did not ensure to obtain documentation of the Virginia Department of Education-sponsored orientation within 90 calendar days of employment for 5 staff as required. Evidence: 1. The records of staff #1 (DOH:1/17/2022), staff #2 (DOH:11/29/2021), staff #3 (DOH:1/26/2022), staff #4 (DOH:1/6/2022) and staff #8 (DOH:10/25/2021) did not contain documentation of the Virginia Department of Education-sponsored orientation course. 2. Administration acknowledged that the staff did not complete the training.
Plan of Correction:	Director will make sure orientation is done within 90 days. Director will use a checklist.
Standard #:	8VAC20-780-245-A
Description:	Based on a review of 10 staff records and interview, the center did not ensure that 3 staff annually completed 16 hours of training appropriate to the age of children in care as required. Evidence: 1. The records of staff #5 (DOH:5/17/2019), staff #7 (DOH:8/12/2019) and staff #9 (DOH:4/28/2005) did not contain record of 16 hours of annual training. 2. Administration acknowledged that the staff had not completed the required annual training.
Plan of Correction:	Director will make sure trainings are done. Director will use checklist to make sure 16 hours of training is complete.
Standard #:	8VAC20-780-245-L
Description:	Based on record review and interview, the center did not ensure that there was always 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: 1. Administration stated that they did not have staff with current Daily Health Observation training.
Plan of Correction:	The director will make sure all faculty have daily health observation training.
Standard #:	8VAC20-780-260-B
Description:	Based on record review and interview, the center did not ensure to obtain annual approval from the health department, or approvals of a plan of correction, for meeting requirements for: water supply; sewage disposal system; and food service, if applicable. Evidence: 1. The last documented health inspection was dated 12/14/2020. 2. Administration acknowledged that an annual approval report from 2021 had not been obtained.
Plan of Correction:	The director contacted the health department to schedule an inspection.