VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lilly's Learning Pad - Jackson Ward Campus
300 W. Clay Street
Richmond, VA 23220
(804) 344-0072

Current Inspector: Cindy Horne (804) 297-4469

Inspection Date: Nov. 3, 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 8VAC20-820 THE LICENSE. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced renewal inspection was conducted on November 3, 2022 from approximately 11:45 am to 1:15 pm. There were 22 children in attendance and a total of 5 staff present. 2 staff records and 2 children?s records were reviewed. All areas of the center were observed including classrooms, bathrooms, and the kitchen. The children were observed eating lunch and taking a nap while the licensing inspector was on the premises. The First Aid Kit had all components. The license, current inspection, and evacuation plan were posted and emergency numbers were posted. Violations were cited as a result of this inspection. 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, 11/16/2022. 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 measure(s).

Violations:

Standard #:	8VAC20-770-60-B
Description:	Based on records review, the center failed to ensure that a sworn statement is completed prior to employment. Evidence: The record for staff #2, date of hire 8/2/22, did not contain evidence of a sworn statement.
Plan of Correction:	Per the Director "as stated the day of the inspection the Director has been going through files and doing file audits and updating the staff records to reflect up to date accurate information. When the inspector arrived the director informed her that she was just about to head to a medical emergency appointment and would do her best to get everything to get and if anything was out of place I could email the file to her. Unfortunately, life happened and neither the inspector nor director adequately nor timely furnished promised information to have this information shared. The staff member does in fact have the sworn statement dated as necessary."
Standard #:	8VAC20-770-60-C-2
Description:	Based on records review, the center failed to ensure that a Central Registry search is mailed no later than 7 days after date of employment and the results are received no later than 30 days after the date of employment. Evidence: The record for staff #2, date of employment 8/2/22, did not contain evidence of a Central Registry search being mailed or received.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-70
Description:	Based on records review, the center failed to ensure to document that two or more references as to character and reputation as well as competency were checked prior to employment. Evidence: The record for staff #2, date of employment 8/2/2022, did not contain documentation of references.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-240-B
Description:	Based on records review, and observation, the center failed to ensure that staff complete orientation training prior to the staff member working alone with children. Evidence: The record for staff #2, date of hire 8/2/2022, did not contain evidence of orientation training. Staff #2 was seen working alone with children.
Plan of Correction:	Per the Director "the orientation was shown to the inspector during the inspection...several items pertaining to this new staff member staff member #2 was kept digital and not yet printed etc. and due to several extenuating factors were not able to be furnished at the time of inspection however, was offered to be furnished once the Director knew all that was missing from the file as we were changing filing systems and was conducting file audits....however, sadly this was not done in a timely manner."
Standard #:	8VAC20-780-280-B
Description:	Based on observation, the center did not ensure that hazardous substances such as cleaning materials were kept in a locked place. Evidence: There was an unlocked cabinet in the preschool bathroom that contained several cleaning agents such as Lysol spray, Clorox wipes, and Windex.
Plan of Correction:	Per the Director "the cabinet in the preschool bathroom is out of reach of children and the chemicals were currently in use by the staff members as it was lunch and nap time so we were cleaning, changing diapers and putting children down for nap."
Standard #:	8VAC20-780-440-E
Description:	Based on observation, the center failed to ensure that there is at least 12 inches of space between occupied cots, beds, and rest mats. Evidence: Several of the mats on the floor where the children were napping were touching, and many of the mats were less than 12 inches apart.
Plan of Correction:	Per the Director "nap mats were rearranged as the students flip down on mats causing them to move etc...several household siblings have trouble sleeping away from their sibling are kept closer to each other such as the several pairs of twins within our center along with some special needs younger siblings...however, once cleaning up from lunch was done mats were rearranged and space out accordingly."
Standard #:	8VAC20-780-500-A
Description:	Based on observation, the center failed to ensure that staff and children?s hands are washed with soap and running water after a diaper change. Evidence: 1) Child #2 received a diaper change. The child was picked up and immediately placed on a mat to take a nap. The child?s hands were not washed after the diaper change. 2) Staff #2 changed child #2's diaper. She picked up the child and placed him on a mat. Staff #2 did not wash her hands.
Plan of Correction:	Per the Director "the new staff member has been training and retrained on the importance of hand washing several times throughout the day...the inspection was being conducted during a very busy time at our center which made the new staff nervous and make basic mistakes which she stated she wiped the children hands with a wet wipe but it was explained to her that soap and running water is best."
Standard #:	8VAC20-780-500-B
Description:	Based on observation, the center failed to ensure that the diapering surface shall only be used for diapering or cleaning children and shall be cleaned and sanitized after each use. Evidence: 1) There were two bottles with milk in them on the end of the diaper changing table. Child #2 was being changed on the changing table. When child #2 was done being changed staff #2 picked up one of the bottles and gave it to child #1. 2) The changing table was not cleaned or sanitized after the child was changed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-570-B
Description:	Based on observation, the center failed to ensure that bottles are not used while the child is in his designated sleeping location. Evidence: It was nap time. Child #1 was lying in a crib drinking a bottle and fell asleep. Child #2 was laying on a mat on the floor while drinking a bottle and fell asleep.
Plan of Correction:	Per the Director "the staff member who is new was reminded of this rule the day of the inspection despite it being her child (over age one on a mat) and the second child was able to hold their own bottle and sit, sit up, stand up in the crib, etc."