VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shepherd's Care Day School
728 Highland Avenue SE
Roanoke, VA 24013
(540) 342-4003

Current Inspector: Rebecca Forestier (540) 309-2835

Inspection Date: Feb. 14, 2023

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. 8VAC20-770 BACKGROUND CHECKS 22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE

Comments:

An unannounced monitoring inspection was conducted on 02/14/2023. There were 47 children, ages 4 months-5 years, 15 staff members providing direct care and supervision and various support staff present during the inspection. The inspector reviewed compliance in the areas of administration, staff qualifications and trainings, staffing and supervision, physical plant, programs, emergencies and nutrition. The children were observed in the following: free choice activities, arts and crafts, during large motor play outside and during lunch. A total of 5 children?s records, 5 staff records and 6 medications were reviewed. The inspector arrived for the inspection at 9:45 am and departed at 1:00 pm. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on record review and staff interviews, the center failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia. Evidence: 1. The record for Staff 1 contained a documented rehire date of 07/15/2022. The date on the fingerprint eligibility letter was 07/19/2022. Staff 7 stated that Staff 1 was a previous employee and that Staff 1 had completed a fingerprint background check prior to the original hire date. More than 12 months had passed between the original employment termination date and the rehire date which required new background checks prior to rehire. 2. The record for Staff 5 contained a documented rehire date of 06/16/2021. The date on the fingerprint eligibility letter was 11/21/2022. Staff 7 stated that Staff 5 was a previous employee and that Staff 5 had completed a fingerprint background check prior to the original hire date. More than 12 months had passed between the original employment termination date and the rehire date which required new background checks prior to rehire.
Plan of Correction:	Will get the fingerprints prior to hire or rehire.
Standard #:	22.1-289.035-B-4
Description:	Based on record review, the center failed to obtain a copy of a child abuse and neglect search and criminal record check from any state in which the individual has resided in the preceding five years. Evidence: The record for Staff 3 contained documentation that Staff 3 has resided outside of the state of Virginia within the preceding five years. There was not an out of state child abuse and neglect registry check from all of the states in which the individual has resided in the preceding five years available for review during the inspection for Staff 3. The documented hire date in the Record for Staff 3 was 01/12/2023.
Plan of Correction:	Will request from each state today.
Standard #:	8VAC20-770-60-B
Description:	Based on record review and staff interviews, the center failed to ensure that an employee must not be employed until the agency has the person?s completed sworn statement or affirmation. Evidence: The record for Staff 5 contained a documented rehire date of 06/18/2021. The sworn statement was dated 06/18/2021. Staff 7 stated that Staff 5 was a previous employee and that Staff 5 had completed a sworn statement prior to the original hire date. More than 12 months had passed between the original employment termination date and the rehire date which required new background checks prior to rehire.
Plan of Correction:	Will get sworn statements prior to hire or rehire.
Standard #:	8VAC20-770-60-C-2
Description:	Based on record review and discussion with staff, the center failed to obtain the finding from a search of the central registry within 30 days of employment. Evidence: 1. The record for Staff 1 contained a documented rehire date of 07/15/2022. The findings from a search of the central registry were dated 09/01/2022. Staff 7 stated that Staff 1 was a previous employee and that a search of the central registry was completed within 30 days of the original hire date. More than 12 months had passed between the original employment termination date and the rehire date which required new background checks prior to rehire. 2. The record for Staff 2 contained a documented hire date of 08/16/2022. The findings from a search of the central registry were dated 09/26/2022. 3. The record for Staff 5 contained a documented rehire date of 06/16/2021. The findings from a search of the central registry were dated 08/10/2022. Staff 7 stated that Staff 5 was a previous employee and that a search of the central registry was completed within 30 days of the original hire date. More than 12 months had passed between the original employment termination date and the rehire date which required new background checks prior to rehire.
Plan of Correction:	Will use the portal to request to get within 30 days.
Standard #:	8VAC20-780-280-B
Description:	Based on observation, the center failed to ensure that hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: There was a plastic spray bottle of Great Value Disinfectant sitting on the sink in the Tigers Classroom. The disinfectant was not locked to prevent access by children.
Plan of Correction:	Will talk to the staff and retrain them.
Standard #:	8VAC20-780-290-A-3
Description:	Based on observation, the center failed to ensure that in areas used by children of preschool age or younger, electrical outlets shall have a protective covers. Evidence: 1. There were 2 uncovered electrical outlets in the Lions Classroom. 2. There were 4 uncovered electrical outlets in the cafeteria. 3. There was 1 uncovered electrical outlet on a power strip in the hallway near the bathroom on the lower floor of the center.
Plan of Correction:	Will cover the outlets.
Standard #:	8VAC20-780-510-G
Description:	Based on document review and interviews with staff, the center failed to ensure that medication shall be labeled with the child?s name, the name of the medication, the dosage amount, and the time or times to be given. Evidence: Medication 5 was not labeled with the child?s name, dosage amount and the times to be given. The label had been pulled off. Staff 6 stated that Medication 5 belonged to Child 4.
Plan of Correction:	Will place a reminder for medications on the cabinet to help remind staff of the requirements.
Standard #:	8VAC20-780-510-P
Description:	Based on document review, the center failed to ensure that when an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Evidence: The authorization form for Medication 6 expired on 01/20/2023. Medication 6 was on-site during the 02/14/2023 inspection.
Plan of Correction:	Will place a reminder for medications on the cabinet to help remind staff of the requirements.