VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Peninsula Pentecostals
404 Sharon Drive
Newport news, VA 23602
(757) 875-5454

VDSS Contact: Michele Patchett (757) 439-6816

Inspection Date: June 26, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-191 Background Checks for Child Welfare Agencies 22VAC40-665 ADMINISTRATION 22VAC40-665 STAFF QUALIFICATIONS & TRAINING 22VAC40-665 PHYSICAL PLANT 22VAC40-665 STAFFING & SUPERVISION 22VAC40-665 PROGAMS 22VAC40-665 SPECIAL CARE PROVISIONS & EMERGENCIES 22VAC40-665 SPECIAL SERVICES

Comments:

Licensing Inspector arrived at 9:30 am and departed at 2:30pm to conduct a Subsidy Health and Safety Inspection. At the time of the tour there were 45 children present with nine staff members, from infancy to school age. Children were observed watching children's programming, doing arts and crafts, arriving to the program and playing freely outdoors. Infants were observed napping, playing independently and sitting in bouncy chairs. The sample size consisted of nine staff records and five children's records. Three medications were reviewed.

Violations:

Standard #:	22VAC40-665-500-F
Description:	Based on observation and inspection of the facility, the vendor did not maintain a confidential current written list of all children's allergies, sensitivities, and dietary restrictions. This list shall be dated and kept in each room or area where children are present. Evidence: The center's allergy lists were not kept confidential as they were observed posted in multiple classrooms.
Plan of Correction:	We will remove all posted allergy lists and keep them in a location and inform need to know staff where they will be kept.
Standard #:	22VAC40-665-540-A
Description:	Based on record review, in two of nine staff records reviewed, the vendor did not ensure that staff shall be evaluated by a health professional and be issued a statement that the individual is determined to be free of communicable tuberculosis (TB). Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall 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: The TB screening results for Staff #3 (hire date 02/08/19) were submitted after employment and were dated 2/11/19. The TB results for Staff #5 (hire date 4/08/19) were not completed within 30 calendar days of the date of employment and were dated 6/27/18.
Plan of Correction:	We will ensure that all staff members provide a TB screening test prior to their first day of employment.
Standard #:	22VAC40-665-610-A
Description:	Based on observation and inspection of the facility, the vendor did not ensure that areas and equipment of the center, inside and outside, shall be maintained in a clean, safe, and operable condition. Evidence: The following potentially unsafe conditions were observed throughout the center and on the premises: 1. On the outdoor play area the following was observed: a. There were broken glass shards on the ground near the storage shed. (Exhibit A) b. One plank on a wooden bridge had deteriorated and exposed a nail. The railings on two bridges were not steady and easily swayed back and forth when touched. (Exhibit B) c. The utility service unit was cracked and split with jagged edges on one side exposing the inside of the unit. (Exhibit C) 2. In the Main Open Play room the following was observed: a. On one of two blue couches the seat was cracked and torn in multiple areas exposing the cushioning beneath. (Exhibit D) b. One tricyle seat was torn and exposing the foam padding underneath.`( Exhibit E)
Plan of Correction:	For the outside items, we will work with our building and grounds worker to correct all things needing attention. For the inside, we will see if they are reparable. If they are not reparable, they will be removed or replaced. by the end of the week.
Standard #:	22VAC40-665-610-C-2
Description:	Based on observation and inspection of the facility, the vendor did not ensure that in areas used by preschool children the electrical outlets shall have protective covers. Evidence: There were three uncovered outlets in the Main Room and five uncovered outlets in the surge protector in the foyer.
Plan of Correction:	We will be more diligent in ensuring outlet covers are where needed and incorporate it into a daily checklist upon arrival.
Standard #:	22VAC40-665-620-A
Description:	Based on observation and inspection of the facility, the vendor did not 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. If a key is used, the key shall not be accessible to children. Evidence: The following unlocked hazardous substances were observed throughout the facility as confirmed by the director: 1. Two Year Old Room-hand sanitizer on a shelf and bleach/water solution in an unlocked cabinet 2. Three-Four Year Old Classroom-bleach/water solution on a shelf, hand sanitizer and an aromatherapy solution on a cabinet 3. Three Year Old Classroom-air freshener on a wooden cubby 4. There were multiple hazardous substances in an unlocked utility closet next to the restrooms used by the children in care.
Plan of Correction:	We will ensure that the closet door remains locked at all times. For the classrooms, today all hazardous things will be moved to the locked closet or we will provide locked spaces for them to be kept if they remain in the classroom .
Standard #:	22VAC40-665-650-C
Description:	Based on observation and inspection of the facility, the vendor did not ensure that facilities operated by, or under the auspices of, a religious institution shall ensure the following ratio requirements are maintained for children from birth to two years: one staff member for every four children. Evidence: One staff person was observed working alone with nine children. The youngest child in the group, Child #1, was 23 months old
Plan of Correction:	We will have to wait until children turn two years old before transitioning them in order to maintain ratios and be in compliance.
Standard #:	22VAC40-665-650-E
Description:	Based on interview with the Director, the vendor did not develop and implement a written policy and procedure that describes how the vendor will ensure that each group of children receives care by consistent staff or team of staff members. Evidence: The center had not developed a consistent care policy.
Plan of Correction:	We will develop a consistent care policy for our center.
Standard #:	22VAC40-665-770-B-5
Description:	Based on interview with the director, the vendor did not ensure that the emergency preparedness plan had been updated to include all required procedures. Evidence: The emergency preparedness plan did not include continuity of operations procedures to ensure that essential functions are maintained during an emergency.
Plan of Correction:	We will update our emergency plan to include the continuity of operations procedures.
Standard #:	63.2(17)-1720.1-A
Description:	Based on record review, in one of nine staff records reviewed, the center did not ensure that staff shall undergo a background check in accordance with subsection B prior to employment or beginning to serve as a volunteer and every five years thereafter. Evidence: As confirmed by the Director, the most recent sworn statement or affirmation for Staff #9 was more than five years old and was dated 7/12/13.
Plan of Correction:	I will make sure that the staff member completes one today and ensure that all staff members complete one every five years.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on record review, in one of nine staff records reviewed, the center did not ensure that staff submit to fingerprinting and obtain results prior to employment. Evidence: The fingerprint results for Staff #5 was dated 4/12/19 and the staff member's start date was 4/8/19 as confirmed by the Director.
Plan of Correction:	We will wait until we receive the fingerprint background before moving forward with courses, orientation and any other processes required to hire new staff.