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: Dec. 2, 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 and concluded on 12/02/2022. The inspector was on site from approximately 9:12 am-1:17 pm. There were 94 children present, ranging in ages from five (5) months to six (6) years, with 17 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 nine (9) child records and nine (9) 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. 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 five (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-B-2
Description:	Based of a review of nine (9) staff records and interview, the center did not ensure to complete a fingerprint background check for one (1) staff prior to the first date of employment as required. Evidence: 1. The record of staff #9 (date of employment: 5/23/2022) contained a fingerprint background check dated 5/26/2022. 2. Administration acknowledged that the fingerprint results were received after the first date of employment.
Plan of Correction:	All fingerprint background check results will ne required prior to the first date of employment. Management will assist applicants in making the fingerprinting appointment during the interview to expedite the process. The director will review fingerprint background checks prior to offers of employment. Required documentation will be reviewed by a second administrator prior to hiring new staff.
Standard #:	22.1-289.035-B-4
Description:	Based on a review of nine (9) staff records and interview, the center did not ensure that one (1) staff had the required out of state background checks within the required time frames. Evidence: 1. The record of staff #9 (date of employment: 5/23/2022) contained a sworn statement that indicated that the staff had resided outside of Virginia within the preceding five (5) years. 2. The record of staff #9 did not contain the out of state criminal history name check that was required prior to the first date of employment for non-NFF states. 3. The record of staff #9 did not contain documentation of an out of state child abuse and neglect search by the end of the 30th day of employment. 4. Administration acknowledged that the out of state background checks had not been completed or requested for staff #9.
Plan of Correction:	A pre hire package has been created to ensure out of state applicants have completed the sworn statement indicating they have lived out of state and all out of state background checks will be required prior to offers of employment. Required documentation will be reviewed by a second administrator prior to hiring new staff. Out of state background checks will be required prior to hire for all applicants residing in now NFF states. Out of state child abuse and neglect searches will be completed on or before the first day of employment and followed up on day 7n and day 15 of employment to ensure receipt. A second administrator will review applicant documentation prior to hiring and will receive a copy of the spreadsheet used to track outstanding documentation.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of nine (9) staff records and interview, the center did not ensure to obtain a central registry finding for four (4) staff by the end of the 30th date of employment as required. Evidence: 1. The record of staff #3 (date of employment: 9/12/2022) did not contain a central registry finding. The record of staff #6 (date of employment: 10/17/2022) contained a central registry finding dated 11/22/2022. The record of staff #8 (date of employment: 7/27/2022) contained a central registry finding dated 9/4/2022. The record of staff #9 (date of employment: 5/23/2022) contained a central registry finding dated 7/14/2022. 2. Administration acknowledged that the findings were not received by the 30th day of employment.
Plan of Correction:	A spreadsheet has been created to track central registry finding for all new hires to ensure receipt/follow-up has been completed within 30 days of hire. The spreadsheet contains checking day 7 that it has been sent and day 15 for an email follow up. The email will include the employees name in the subject line to ensure each follow up will be for each individual employee.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of nine (9) staff records and interview, the center did not ensure that nine (9) staff members submitted documentation of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children. Documentation must have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department. Evidence: 1. The record of staff #1 (date of employment: 11/16/2022) did not contain a TB screening. The record of staff #2 (date of employment: 11/30/2022) did not contain a TB screening. The record of staff #3 (date of employment: 9/12/2022) contained a TB screening dated 7/16/2022.The record of staff #4 (date of employment: 11/17/2022) did not contain a TB screening.The record of staff #5 (date of employment: 11/28/2022) did not contain a TB screening. The record of staff #6 (date of employment: 10/17/2022) did not contain a TB screening.The record of staff #7 (date of employment: 8/22/2022) did not contain a TB screening. The record of staff #8 (date of employment: 7/27/2022) contained TB screening dated 8/16/2022. The record of staff #9 (date of employment: 5/23/2022) contained a TB screening dated 5/25/2022. 2. Administration acknowledged that the TB screenings were not received within the required time frame.
Plan of Correction:	Tuberculosis screening will be required prior to employment (unless a negative screening has been documented within the last 30 days). This requirement has been added to the employee file checklist and will be reviewed by at least two members of management prior to the employees first day to ensure it is completed.
Standard #:	8VAC20-780-70
Description:	Based on a review of nine (9) staff records and interview, the center did not ensure that complete records were kept for eight (8) staff. Evidence: 1. The record of staff #1 (date of employment: 11/16/2022) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment. The record of staff #2 (date of employment:11/30/2022) did not contain the required references. The record of staff #3 (date of employment:9/12/2022) did not contain the required references. The record of staff #4 (date of employment: 11/17/2022) did not contain the required references. The record of staff #5 (date of employment:11/28/2022) did not contain the required references. The record of staff #6 (date of employment:10/17/2022) did not contain documentation to demonstrate that the individual possessed the required orientation. Administration stated that the orientation was completed but not documented. The record of staff #7 (date of employment: 8/22/2022) did not contain documentation to demonstrate that the individual possessed the required orientation. Administration stated that the orientation was completed but not documented. The record of staff #9 (date of employment: 5/23/2022) contained incomplete references. The documented references did not include the results of the phone calls. 2. Administration acknowledged that the records were incomplete.
Plan of Correction:	Staff records will be completed within the first day of employment. Applicants will be asked to bring reference letters to their interview. If they are not able, we will ask that they complete the reference section on their application before leaving their interview. References will be verified prior to hiring. Orientation documentation will be completed on the first day of employment. Faculty files will be reviewed by a second administrator.
Standard #:	8VAC20-780-240-A
Description:	Based on a review of nine (9) staff records and interview, the center did not ensure that two (2) staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: 1. The record of staff #7 (date of employment: 8/22/2022) did not contain documentation that the course had been completed. The record of staff #8 (date of employment: 7/27/2022) did not contain documentation that the course had been completed. 2. Administration acknowledged that the staff had not completed the required orientation course.
Plan of Correction:	The VDOE sponsored orientation course will be required within the first 30 days of employment and documented in the faculty's file. The completion of this requirement will be added to the employee 30 day review checklist to ensure it is completed within the required time frame.
Standard #:	8VAC20-780-240-E
Description:	Based on a review of nine (9) staff records and interview, the center did not ensure that within 30 days of the first date of employment, two (2) staff completed the required orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care. Evidence: 1. The record of staff #3 (date of employment: 9/12/2022) did not contain documentation of CPR and first aid orientation. The record of staff #6 (date of employment: 10/17/2022) did not contain documentation of CPR and first aid orientation. 2. Administration acknowledged that the CPR and first aid orientation had not been completed within the 30 days.
Plan of Correction:	First aid and cpr orientation will be included in the faculty orientation which will be required on the first date of employment. First aid and cpr certification will be required within the first week of employment. This requirement has been added to the employee file checklist. If the employee does not have the certification at the time of hire, an appointment to take the first aid and cpr class will be made and and paid for by management staff for the employee within the first week of employment to ensure certification is completed. All new hire checklists will be reviewed after 7 days of employment to track the requirement.
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. In eight (8) classrooms, rest mats were observed with rips and tears that exposed the foam cushioning. In the preschool room, two (2) children's arm chairs were observed with torn fabric. Areas of chipped and peeling paint were observed in the toddler and toddler two classrooms. Rust was observed on the hinges of four (4) cribs in the infant room. 2. Administration acknowledged that the areas required maintenance.
Plan of Correction:	Periodic inspections of the center's areas and equipment are done and repair requests are completed. A notebook to log repair requests was created and is stored in the director's office for staff to access at any time. The log is reviewed regularly and updates on progress and completion of repairs are made in the log by management. In the future, items with rips and tears will be removed immediately and replacement items will be ordered. One box of rest mats arrived at the center and ripped mats have been replaced. More replacement rest mats have been ordered. The chairs with the torn fabric have been replaced. Mats replaced on 12/5/2022. Additional mats ordered on 12/15/2022. The crib hinges will be repaired by 1/1/2023. Areas of chipped and peeling paint will be repainted by Gomez Painting before 1/1/2023.
Standard #:	8VAC20-780-340-D
Description:	Based on observation, a review of records and interview, the center did not ensure that in each grouping of children at least one staff member who met the qualifications of a program leader or program director was regularly present. Evidence: 1. In the preschool room staff #3 was observed working in single ratio with 10 children. Staff #3 was identified as an aide during interview as well as in the staff's record. 2. Administration acknowledged that a lead was not present in the preschool room and that staff #3 regularly worked alone.
Plan of Correction:	A lead qualified faculty member has been hired for the preschool classroom. All classes are staffed with a lead qualified faculty member and an assistant. In the event that a program lead in any classroom leaves the school, a program director or another program lead qualified staff will take over the role in that classroom until a replacement program lead is hired. If this is not possible, an existing staff member will be enrolled in the CDA program to fill the program lead requirement.
Standard #:	8VAC20-780-530-A-1
Description:	Based on observation and interview, the center did not ensure that at least one staff in each classroom or area where children were present had current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children in care. Evidence: 1. In the preschool classroom, staff #3 was observed working alone with 10 children. Staff #3 stated that she was not CPR certified. 2. Administration acknowledged that staff #3 was not CPR certified.
Plan of Correction:	All staff will be required to have first aid and cpr certification. Any faculty member without certification will be required to become certified within their first week of hire and will not be left alone in any class until certified. The first aid and cpr certification class will be set up and paid for by management to ensure it is completed in the timeframe required.
Standard #:	8VAC20-780-530-A-2
Description:	Based on observation and interview, the center did not ensure that at least one staff in each classroom or area where children were present had current certification in certification in first aid. Evidence: 1. In the preschool classroom, staff #3 was observed working alone with 10 children. Staff #3 stated that she was not first aid certified. 2. Administration acknowledged that staff #3 was not first aid certified.
Plan of Correction:	All staff will be required to have first aid and cpr certification. Any faculty member without certification will be required to become certified within their first week of hire and will not be alone in any class until certified. If the employee does not have the certification at the time of hire, an appointment to take the first aid and cpr class will be made and paid for by management staff for the employee within the first week of employment to ensure certification is completed.
Standard #:	8VAC20-780-550-D
Description:	Based on a review of documentation and interview, the center did not ensure to implement a monthly practice evacuation drill. Evidence: 1. The center's drill logs were reviewed. An evacuation drill was not documented in November of 2022. 2. Administration stated that an evacuation drill had not been completed in November.
Plan of Correction:	Monthly evacuation drills will be planned in advance and the dates of the drills will be added to a shared calendar with all management to ensure they are conducted.