VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tri-County Community Action Agency, Inc. - Boydton
117 Mayfield Drive
Boydton, VA 23917
(434) 710-6998

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: Oct. 31, 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 minors records 22.1 Background Checks Code, Carbon Monoxide 22.1 Early Childhood Care and Education

Comments:

An unannounced monitoring inspection was initiated on 10/31/2022 and concluded on 11/2/2022. The inspector was on site on 10/31/2022 from approximately 9:08 am-10:35 am. There were five (5) children present, ranging in ages from three (3) to four (4) years, with two (2) 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 five (5) child records and three (3) staff records were reviewed. Staff records were reviewed remotely on 11/2/2022. 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 #:	8VAC20-770-60-C-2
Description:	Based on a review of three (3) staff records and interview, the center did not ensure that one (1) record contained a central registry finding within 30 days of employment as required. Evidence: 1. The record of staff #3 (date of employment: 10/18/2021) contained a central registry finding dated 12/14/2021. 2. Administration acknowledged that they did not have the finding within 30 days.
Plan of Correction:	request page was sent to licensing inspector
Standard #:	8VAC20-780-140-A
Description:	Based on a review of five (5) child records and interview, the center did not ensure that two (2) children had a physical examination by or under the direction of a physician: 1. Before the child's attendance; or 2. Within 30 days after the first day of attendance. Evidence: 1. The record of child #4 (date of attendance: 9/12/2022) and child #5 (date of attendance 9/19/2022) did not contain a physical record. 2. Administration acknowledged that the reports were not obtained.
Plan of Correction:	child #4 physical form received-Child #5 physical form was received on 10/31/2022- corrected the same day
Standard #:	8VAC20-780-70
Description:	Based on a review of three (3) staff records and interview, the center did not ensure that one (1) record contained the required information. Evidence: 1. The record of staff #3 (date of employment: 10/18/2021) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment as required. 2. Administration acknowledged that the references were not in the record.
Plan of Correction:	will request 2 records of documentation from staff member
Standard #:	8VAC20-780-240-A
Description:	Based on a review of three (3) staff records and interview, the center did not ensure that one (1) staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: 1. The record of staff #3 (date of employment 10/18/2021) did not contain documentation of the course completion. 2. Administration acknowledged that it was not completed.
Plan of Correction:	staff member will have 30 days to complete training
Standard #:	8VAC20-780-245-A
Description:	Based on a review of three (3) staff records and interview, the center did not ensure that one (1) staff annually completed a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1. The record of staff #3 (date of employment: 10/18/2021) did not contain 16 hours of annual training. 2. Administration acknowledged that the 16 hours of training was not in the record.
Plan of Correction:	Staff member will be given virtual trainings to complete to get to 16 hours.
Standard #:	8VAC20-780-270-A
Description:	Based on observation and interview, the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1. A blue climbing structure was observed that had multiple areas of rust. The fabric on top of the climber was ripped. Eight (8) bikes were observed that contained rust. One (1) bike had a torn seat, one (1) bike had a missing handle and one (1) bike had a seat with torn fabric. 2. Administration acknowledged the areas required maintenance.
Plan of Correction:	maintenance will see if they can remove the rust. If rust cannot be removed will remove play equipment.
Standard #:	8VAC20-780-540-C
Description:	Based on observation and interview, the first aid kit did not include all required supplies. Evidence: 1. The first aid kit contained one (1) triangular bandage. The kits are required to contain more than one. 2. Administration acknowledged that the kit was incomplete.
Plan of Correction:	add one for triangular bandage to first aid kit