VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Frost Montessori School of Albemarle
1553 Delphi Drive
Charlottesville, VA 22911
(434) 979-5223

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: Sept. 13, 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 13, 2022. The director was available during the inspection. There were 74 children present, ranging in ages from 1 year to 5 years, with 9 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 7child records and 7 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. An Intensive Plan of Correction conference will be scheduled. 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 #:	22.1-289.035-B-2
Description:	Based on a review of staff records and interview on September 13, 2022, the center failed to obtain a fingerprint based national criminal record check prior to the first day of employment for each staff. Evidence: 1. The record of staff #1 (hired 8/1/22) contained documentation of fingerprints dated 9/4/19. 2. The record of staff #3 contained documentation of fingerprints dated 7/13/22. Staff #3 completed staff orientation on 6/29/22. 3. The record of staff #6 contained documentation of fingerprints dated 7/20/22. Staff #6 completed staff orientation on 7/8/22. 4. The record of staff #7 (hired 8/1/22) contained documentation of fingerprints dated 8/22/22. 5. Staff #8 confirmed that staff orientation training has been given prior to background checks being completed.
Plan of Correction:	See Intensive Plan of Correction
Standard #:	22.1-289.035-B-4
Description:	Based on a review of staff records and interview on September 13, 2022, the center failed to obtain results of a check of the out-of-state criminal history record check and out-of-state sex offender registry prior to employment for each employee and did not request an out-of-state search of the child abuse and neglect registry or equivalent by the end of the 30th day of employment for each employee who has resided in any other state in the preceding five years. Evidence: 1. The record of staff #1 (hired 8/1/22) contained documentation of an out-of-state sex offender search dated 8/9/22. There was no documentation of an out-of-state criminal history record check. Staff #1 indicated living out-of-state in the previous five years on the staff's sworn disclosure statement. 2. The record of staff #6, who began work on 7/8/22, contained documentation of an out-of-state sex offender search dated 7/20/22. There was no documentation of an out-of-state central registry search. Staff #6 indicated living out-of-state in the previous five years on the staff's sworn disclosure statement. 3. Staff #8 confirmed the out-of-state checks were late or missing.
Plan of Correction:	See Intensive Plan of Correction
Standard #:	8VAC20-770-60-B
Description:	Based on a review of staff records on September 13, 2022, the center failed to obtain a sworn statement from each staff prior to employment. Evidence: 1. The record of staff #1 (hired 8/1/22) contained a sworn statement dated 8/4/22. 2. The record of staff #4 (hired 3/6/22) contained a sworn statement dated 3/15/22.
Plan of Correction:	See Intensive Plan of Correction
Standard #:	8VAC20-780-160-A
Description:	Based on a review of staff records and interview on September 13, 2022, the center failed to ensure that each staff submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: The record of staff #6 (hired 8/1/22) contained documentation of a tuberculosis screening dated 9/5/22. Staff #8 confirmed that school started on 8/22/22 and the staff came in contact with children. Staff #8 confirmed the tuberculosis screening was late.
Plan of Correction:	Staff member was late in submitting TB test and has been reminded to turn in all necessary paperwork in a timely fashion. A second reminder will be in place for documents set to expire moving forward.
Standard #:	8VAC20-780-40-E
Description:	Based on staff interview and a review of children's records on September 13, 2022, the center failed to operate within the terms of the current license issued by the department. Evidence: 1. The center is currently licensed to serve ages 2 years - 6 years, 11 months old. 2. Staff in the toddler classroom identified the youngest child in the room, child #5, as being 1 years old. 3. The record of child #5 indicated the child was 1 years old at the time of enrollment on 8/22/22.
Plan of Correction:	See Intensive Plan of Correction
Standard #:	8VAC20-780-90--A
Description:	Based on a review of children's records and interview on September 13, 2022, the center failed to ensure a written agreement between the parent and the center was in each child's record by the first day of the child's attendance. Evidence: The records of child #1 and child #3 (enrolled 8/22/22) contained written agreements dated 8/26/22. The record of child #2 (enrolled 8/22/22) contained a written agreement dated 8/23/22. Staff #8 confirmed the written agreements were not obtained and placed in the record by the first day of each child's attendance.
Plan of Correction:	Staff will confirm all required documents are in place in a timely manner.
Standard #:	8VAC20-780-280-B
Description:	Based on observation on September 13, 2022, the center failed to ensure that hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. The toddler classroom bathroom contained a cabinet with broken locks. The cabinet contained Steramine spray, Clorox spray, Lysol spray, Neutron NI-712 spray, and 5 containers of Lysol wipes. The labels on these materials contained the warnings "keep out of reach of children, "warning" and "caution." 2. The children's house 1 classroom bathroom contained a bottle of Steramine spray on a shelf and Dawn dish soap in an unlocked cabinet under the sink in the classroom. The labels on these materials contained the warnings "keep out of reach of children" and "warning." 3. The children's house 2 classroom contained disinfectant wipes on a shelf. The label on this material contained the warnings "keep out of reach of children" and "caution." 4. The children's house 3 classroom contained Metal Polish on a shelf. The label on this material contained the warnings "keep out of reach of children" and "caution." 5. The Big Room contained a bottle of Steramine spray on a shelf. An unlocked cabinet contained Murphy's Oil Soap, Steramine spray, and hand sanitizing wipes. The labels on these materials contained the warnings "keep out of reach of children" and "warning."
Plan of Correction:	See Intensive Plan of Correction
Standard #:	8VAC20-780-500-B
Description:	Based on observation and interview on September 13, 2022, the center failed to ensure that a diaper was disposed of in such a way that the soiled diaper did not touch an exterior surface of the storage system during disposal. Evidence: Staff #3 was observed assisting child #6 with toileting. After toileting, staff #3 told child #6 to put the child's diaper in the trash. Child #6 was observed picking up the diaper from the floor, and allowing it to touch the outside of the trashcan, prior to placing it in the trash can.
Plan of Correction:	Staff members in toddler room have been instructed again on the proper disposal of diapers/Pullups. (They have been instructed to abandon the Montessori philosophy of independence when diapers/Pull ups are involved.)
Standard #:	8VAC20-780-520-C
Description:	Based on observation, review of records, and staff interviews on September 13, 2022, the center failed to ensure if diaper ointment or cream is used there shall be written parent authorization noting any known adverse reactions; the products shall be labeled with the child's name; and a record shall be kept that includes the child's name, date of use, frequency of application and any adverse reactions. Evidence: 1. Desitin was observed in the bathroom cabinet in the toddler classroom. The Desitin was not labeled with a child's name. 2. Staff #3 said that the Desitin was used on child #5 last week but staff #3 couldn't recall the exact day. 3. Staff #3 stated they don't keep record of the use of the Desitin and that the Desitin is used on any child if they appear red or dry. 4. Staff #5 confirmed there was no parent authorization for use of the Desitin for child #5.
Plan of Correction:	Staff will always have medicines cleared and properly documented by assistant director before having them in the classroom for use.
Standard #:	8VAC20-780-530-A-1
Description:	Based on a review of staff records and interview on September 13, 2022, the center failed to have one staff member in each classroom with current certification in cardiopulmonary resuscitation (CPR). Evidence: In the children's house I classroom staff #9 and staff #10 were teaching together. Based on a review of CPR certifications it was determined that staff #9 contained documentation of a CPR certification that expired 10/8/19. Staff #10 does not have documentation of a CPR certification. Staff #8 confirmed there was no staff in the classroom with CPR certification.
Plan of Correction:	Staff member #9 was recertified for CPR/FA/ AED on September 20? 2022. Staff member #10 provided documentation of current CPR/FA/ AED.
Standard #:	8VAC20-780-530-A-2
Description:	Based on a review of staff records and interview on September 13, 2022, the center failed to have one staff member in each classroom with current certification in first aid. same comment and question as above Evidence: In the children's house I classroom, staff #9 and staff #10 were teaching together. Based on a review of first aid certifications it was determined that staff #9 contained documentation of a first aid certification that expired 10/8/19. Staff #10 does not have documentation of a first aid certification. Staff #8 confirmed there was no staff in the classroom with first aid certification
Plan of Correction:	Staff member #9 recertified for CPR/FA/ AED on 9/20/2022. Staff member #10 provided documentation of current CPR/FA/ AED.