VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Good Shepherd Lutheran Church
1401 Old Hundred Road
Midlothian, VA 23114
(804) 897-0260

VDSS Contact: Lynn Powers (804) 840-8260

Inspection Date: July 29, 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

Technical Assistance:

N/A

Comments:

An unannounced monitoring inspection was conducted Monday, July 29, 2019 to determine the center's compliance with religious exempt requirements. The inspection was initiated at approximately 11:45 AM and concluded at approximately 2:45 PM. The center was in compliance with the required staff to child ratio. The following was observed for a total of 88 children in the building: Infants ? 2 children with 1 staff Infants ? 5 children with 2 staff Toddlers ? 5 children with 2 staff Toddlers ? 5 children with 2 staff Twos ? 3 children with 2 staff Twos ? 8 children with 2 staff Threes ? 12 children with 2 staff Threes ? 6 children with 1 staff Threes & Fours - 11 children with 2 staff JK - 7 children with 1 staff School Age - 24 children with 3 staff During the inspection, children were observed playing outside, taking bathroom breaks and washing hands, eating lunch, reading books, building with blocks, coloring, working puzzles and resting at naptime. During the inspection 10 children's records and 10 staff records were reviewed. All areas of the center used by children were inspected. Policies and procedures were discussed. Written notification to parents and the public was reviewed. Violations were cited during the inspection. See violation notice for additional details. The provider must send documentation to the licensing inspector that the background checks have been requested no later than 10 days following this notification dated July 29, 2019. If you have any questions, please contact the licensing inspector at (804) 662-9790.

Violations:

Standard #:	22VAC40-191-40-D-2
Description:	Based on review of records, it was determined that the center did not ensure that all staff and volunteers had a search of the central registry within the first 30 days of employment or volunteering. Evidence: The records for Staff #6 (hire date 11/14/18) and Staff #10 (hire date 12/27/18) did not contain central registry results. Staff #6 and Staff #10 were observed working alone with the children during the inspection.
Plan of Correction:	I have reached out the local agency to see if the central registry forms have been received and I am waiting to hear back. I will reach out again and if the forms have not been received, we will re-send.
Standard #:	63.2(17)-1716-B-4
Description:	Based on review of five children's records, one record did not have the required updated immunization documentation. Evidence: The record for Child #8 contained one documentation of immunizations occurring on 06/18/18. Child #8 was 13 months of age when the child started attending the facility on 09/04/18. Immunization records are required to be updated at least every six months for children under the age of two. The parent handbook indicated immunization records are required to be updated.
Plan of Correction:	I will contact the parents and have an updated immunization record added to the record.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on review of 10 records, the center did not obtain satisfactory results of the finger-print based national criminal background check for two staff prior to employment. Evidence: The record for Staff #5 (hire date 06/08/18) contained satisfactory results of the finger-print based national criminal background check dated 07/10/2018. The record for Staff #10 (hire date 12/27/2018) contained satisfactory results of the finger-print based national criminal background check dated 01/17/2019.
Plan of Correction:	We will ensure results of finger-print national background checks are obtained prior to staff being hired.
Standard #:	63.2(17)-1720.1-B-3
Description:	Based on the review of the 10 staff records, the center did not request a search of out-of-state founded complaints of child abuse for one staff member who has lived outside of Virginia within the last five years. Evidence: The record for Staff #6 (hire date 11/14/18) indicated the staff member has lived outside of Virginia within the last five years. The record did not contain documentation of a request for founded complaints of child abuse from the states the staff member indicated she had lived in within the last five years. As of 07/29/19, the out of state searches have not been requested for Staff #6.
Plan of Correction:	We will request the out-of-state checks and add the results to the record.