VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Legacy Christian Fellowship
5933 Valley Pike
Stephens city, VA 22655
(540) 252-0238

VDSS Contact: Julie Kunowsky (540) 430-9256

Inspection Date: July 9, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-191 Background Checks for Child Welfare Agencies 63.2 Child Abuse & Neglect 63.2(17) License & Registration Procedures

Comments:

An unannounced monitoring inspection was conducted on 7/9/19 from 10:35 am until 12:45 pm to review the religious exempt requirements. At the time of the inspection there were 34 children with three staff. The sample size consisted of seven staff's records. Children and staff were observed during lunch, bathroom break, hand washing, preparing to leave for the pool, transitions and behavioral guidance. Violations were found during this inspection and are documented on the violation notice. If you have questions or concerns contact the licensing inspector at (540) 292-5933 for further assistance.

Violations:

Standard #:	22VAC40-191-40-D-2
Description:	Based on record review and interview, the center failed to ensure all staff completed a sworn disclosure statement prior to the first day of employment and a central registry record check within 30 days of employment. Evidence: 1. The records for all seven staff were reviewed. None of the seven staff have a sworn statement or affirmation. 2. Staff 1, start date 9/14, did not have a search of central registry. 3. The administrator stated they have not required staff to complete a sworn statement or affirmation and they do not have a search of central registry for staff 1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	63.2(17)-1716-A
Description:	Based on interview, the center failed to provide a written disclosure to parents and guardians of the children in the center advising the qualifications of personnel and post the fact that the center is exempt from licensure. Evidence: 1. The parent handbook did not contain information regarding the qualifications of the personnel. 2. The director stated they do not provide information to parents in writing regarding the qualifications of personnel and the center has not posted that the center is exempt from licensure.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	63.2(17)-1716-A-4
Description:	Based on record review, the center failed to ensure all staff obtained documentation from a physician that they are free from any disability which would prevent him/her from caring for children under his/her supervision by the first date of employment and annually thereafter. Evidence: 1. The records of seven staff were reviewed. The record for staff 6 did not have a staff health form and the record for staff 7 had a staff health form dated 6/18/18. 2. The administrator verified they do not have staff health forms for staff 6 and that staff 7's health form is expired.
Plan of Correction:	Staff 6 will be required to obtain staff health forms and staff 7 will be required to obtain an updated staff health form. In the future all new staff will be required to provide a staff health form prior to working with children and yearly there after.
Standard #:	63.2(17)-1716-A-5-a
Description:	Based on observation and interview, the center failed to to comply with the requirements set by their religious exempt status as it refers to the age range. Evidence: 1. Upon entry a large group of school age children were assembled in the cafeteria. The center's statement of intent list the age range as three-years-old to four-years-old. 2. The director stated during the school year they have a three and four-year-old program and a before and after school program for ages three to twelve. During the summer they offer summer care to ages four to twelve.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	63.2(17)-1716-A-6
Description:	Based on interview, the center failed to provide a written disclosure to parents and guardians of the children in the center advising information regarding the enrollment capacity, food services, health requirements for staff, and public liability insurance. Evidence: 1. The parent handbook was reviewed and information regarding enrollment capacity, food services, health requirements for staff, and public liability insurance was not in the parent handbook. 2. The director stated they do not provide this information to parents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	63.2(17)-1716-B-3
Description:	Based on interview, the center failed to establish and implement a procedure regarding daily simple health screening and exclusion of sick children by a person trained to perform such screenings. Evidence: 1. A review of the staff handbook, parent handbook and staff records had no procedure for a daily simple health check and no staff trained in conducting a daily simple health check. The center does not have a policy in exclusion of sick children. 2. The director stated they do not have a specific policy on conducting a daily simple health check and no staff have been trained to conduct a daily simple health check.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	63.2(17)-1716-B-4
Description:	Based on interview, the center failed to establish and implement a procedure to ensure that all children in the center are in compliance with immunization provisions. Evidence: The director stated they do not have a procedure in which they ensure children that attend the summer camp are in compliance with immunization provisions. If the children attend the school during the school year and attend the camp, the school would have the immunizations on record but they do not require it for summer camp.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	63.2(17)-1716-B-5
Description:	Based on observation and interview, the center failed to implement a procedure to ensure all areas of the premises accessible to children are free of obvious injury hazards, including providing and maintaining cushioning material under playground equipment. Evidence: 1. The playground has a dusting of loose mulch under the swings, at the end of the slide and under the climbing dome. The back of the seat on the wood stationary race car is warped and splintered. 2. The administrator stated the center has a maintenance person that maintains the building and playground. 3. The director stated they have a group of volunteers that come in once a year the week before school starts and spreads mulch and repairs any areas needed.
Plan of Correction:	Not available online. Contact Inspector for more information.