VIRGINIA DEPARTMENT OF SOCIAL SERVICES

VCUHS CDC @ N-DECK
607 North 10th Street
Richmond, VA 23298
(804) 828-6291

Current Inspector: Lauren Bickford (540) 280-0742

Inspection Date: Dec. 19, 2023 and Dec. 21, 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. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Comments:

A renewal inspection was conducted on 12/19/2023 from approximately 1:00 p.m. ? 5:00 p.m. and 12/21/2023 from approximately 9:40 a.m. to 1:00 p.m. Personnel records were reviewed off-site. There were 115 children present ranging from infants to five years old and eighteen staff supervising. Ten child records and eleven staff record were reviewed. The information gathered during the inspection determined violations with applicable standards or law. Please sign and 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. 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 preventive measure(s). If you have any questions related to this inspection, please contact Susan Ellington-Sconiers, Licensing Inspector at 804-588-2368 or susan.ellingtonsconiers@doe.virginia.gov.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on record review, the provider failed to ensure that all applicants for employment shall submit to fingerprinting and undergo a national criminal background check prior to employment. Evidence: The record for staff S3, employed 07/23/2023 did not have results of a national criminal background check prior to the first day of employment. The results of the national criminal background check are dated 09/01/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22.1-289.035-B-4
Description:	Based on staff record review, the provider failed to obtain the results of a sex offender registry search, out of state criminal history name check, and out-of-state child abuse and neglect search from any state in which the individual has lived in the preceding five years. Evidence: The staff record for S5, employed 09/03/2023 documented S5 having lived out-of-state in two different states in the last five years. The record did not contain: a sex offender searches for one of the two states in which the individual lived in the preceding five years; the results of the two out-of-state child abuse and neglect searches; and the criminal history name check for two of the two states the individual lived in the preceding five years. Staff record for S6, employed 09/03/2023 documented S6 having lived out-of-state in the last five years. The record did not contain the results of a child abuse and neglect search.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-130-A
Description:	Based on record review, the provider failed to ensure that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: The record for C2, enrolled 09/18/2023 documented immunizations being received 12/22/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-130-E
Description:	Based on child record review, the provider failed to obtain documentation of additional immunizations once every six months for children under the age of two years. Evidence: The record for C4, under the age of 2, enrolled 06/06/2022 did not contain additional immunizations due within six months of immunizations in the record dated 12/06/2022. The record for C10, under the age of 2, enrolled 11/28/2022 did not contain additional immunizations due within six months of immunizations dated 01/24/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-140-A
Description:	Based on record review, the provider failed to ensure that each child shall have a physical examination by or under the direction of a physician before the child?s attendance or within 30 days after the first day of attendance. Evidence: The record for C2, enrolled 09/18/2023 documented the physical examination being received 12/22/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-150-B
Description:	Based on child record review, the provider failed to assure that each report of immunizations shall be signed by a licensed physician, the physician?s designee, or an official of a local health department. Evidence: The immunizations for C10 dated 01/24/2023 were not signed by the licensed physician, the physician?s designee, or an official of a local health department.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-70
Description:	Based on staff record review, the provider failed to ensure that 10 of 11 records contained required information. Evidence: 1. Record for S1, employed 12/10/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities. 2. Record for S2, employed 12/10/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 3. Record for S3, employed 07/23/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 4. Record for S4, employed 02/05/2023 did not contain: employment references; information about any health problems that may interfere with fulfilling the job responsibilities; and telephone number of a person to be notified in an emergency which shall be kept at the center. 5. Record for S5, employed 09/03/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 6. Record for S7, employed 06/25/2023 did not contain: employment references; information about any health problems that may interfere with fulfilling the job responsibilities; and a telephone number of a person to be notified in an emergency which shall be kept at the center. 7. Record for S8, employed 08/06/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities. 8. Record for S9, employed 08/20/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 9. Record for S10, employed 02/19/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities and a telephone number of a person to be notified in an emergency which shall be kept at the center. 10. Record for S11, employed 03/05/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-90--A
Description:	(Repeat violation) Based on review of ten children records, the provider did not ensure that four of ten children?s records contained a written agreement between the parents and the center shall be in each child?s record by the first day of the child?s attendance. Evidence: The records for C2, enrolled 09/18/2023, C6, enrolled 10/16/2023, C7, enrolled 08/14/2023, and C10 enrolled 11/28/2023 did not contain signed written agreements between the parents and the center.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-240-A
Description:	(Repeat violation) Based on record review, the provider failed to ensure that staff shall complete the Virginia Department of Education-sponsored orientation course within 90 days of employment. Evidence: The record for S6, employed 09/03/2023 contained a certificate of completion of the Virginia Preservice Training dated 12/12/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-260-A
Description:	(Repeat violation) Based on interview, the center failed to provide an annual inspection report from the appropriate fire official having jurisdiction. Evidence: The center failed to have an annual fire inspection report inspection available for viewing during the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-270-A
Description:	(Repeat violation) Based on observation, the provider did not ensure that all areas of the center be maintained in a clean, safe, and operable condition. Evidence: The black metal fence surrounding the playground had several loose panels and the garden fabric near the play structure tunnel was loose creating a tripping hazard.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-550-P
Description:	Based on review of the center?s written record of children serious or minor injuries the center failed to document the date and time when parents were notified of the injuries. Evidence: The written records for serious or minor injuries for C11 (12/06/2023), C12 (10/09/2023), C13 (10/03/2023), C14 (11/28/2023), C15 (11/29/2023), and C16 (11/22/2023 and 12/05/2023) did not document the date and time when parents were notified of the injuries.
Plan of Correction:	Not available online. Contact Inspector for more information.