VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Grace Covenant Presbyterian Church
1617 & 1627 Monument Avenue
Richmond, VA 23220
(804) 213-0200

VDSS Contact: Molly Muscat (804) 588-2367

Inspection Date: Aug. 15, 2019

Complaint Related: No

Areas Reviewed:

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

Technical Assistance:

N/A

Comments:

An unannounced monitoring inspection was conducted Thursday, August 15, 2019 to determine the center's compliance with religious exempt requirements. The inspection was initiated at approximately 9:40 AM and concluded at approximately 2:15 PM. A total of 69 children were present during the inspection and the following staff to child ratios were observed: Infants I: 7 children and 2 staff Infants I: 6 children and 2 staff Yellow Walkers: 3 children and 2 staff Blue Walkers: 5 children and 2 staff Toddlers I: 12 children and 3 staff Toddlers II: 12 children and 2 staff Advanced Toddlers: 8 children and 2 staff Early Pre-K: 7 children and 1 staff Pre-K: 9 children and 1 staff Children were observed playing with toys, playing outside, having books read to them, painting, singing songs, creating penguins, playing in the sensory table, washing hands and taking bathroom breaks, eating lunch and resting at nap time. All areas of the center were inspected including the classrooms, hallways, bathrooms and outdoor play area. During the inspection, 10 children?s records and 10 staff records were reviewed. Policies and procedures were discussed and information disclosed to parents, guardians and public was reviewed. Violations were cited during the inspection. See the violation notice for additional information. 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 August 15, 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 10 staff records, the center did not ensure that all staff and volunteers had a sworn statement of affirmation prior to the beginning of employment and a search of the central registry within the first 30 days of employment or volunteering. Evidence: 1. The record for Staff #2 (hire date 11/26/18) contained a sworn statement dated 12/26/18 and the record for Staff #5 (hire date 03/18/19) contained a sworn statement dated 03/26/19. Sworn statements are required to be obtained prior to beginning employment. 2. The records Staff #2 (hired date 11/26/18), Staff #3 (hire date 10/29/18), Staff #4 (hire date 12/06/18) and Staff #5 (hire date 03/18/19) did not contain findings for a central registry. A search for the central registry is required to be obtained within the first 30 days of employment. 3. The record for Staff #1 (hire date 11/14/17) contained a search for central registry dated 02/01/18. The record for record for Staff #9 (hire date 12/18/10 contained a search for a central registry dated 07/31/19, and the record for Staff #10 (hire date 07/31/17) contained a search for a central registry dated 01/22/18. The search for the central registry is required to be obtained with the first 30 days of employment.
Plan of Correction:	We have audited the files and realized staff records were missing some of the required background checks and other background checks were requested late. We have sent off for many of these required checks. We will follow up with the agency and if any of the requests have not been received we will request the searches again. Proof will be submitted to the licensing inspector within 10 days as evidence of compliance.
Standard #:	63.2(17)-1716-A
Description:	Based on interview and documentation review, the center did not disclose in writing to the parents or guardians of the children in the center the qualifications of the personnel employed. Evidence: During the inspection conducted on August 15, 2019, the information disclosed in writing to the parents or guardians of children was reviewed. Information regarding the qualifications of personnel was not disclosed to parents or guardians in writing.
Plan of Correction:	We were not aware this information was required to be disclosed in writing. A disclosure form was given to management during the inspection. The form with the required information will be completed and included in the information distributed to the parents and guardians.
Standard #:	63.2(17)-1716-A-6
Description:	Based on review of documentation and interview, the center did not describe in written statement to parents or guardians and made available to general public aspects regarding the center's operations concerning physical facilities, enrollment capacity, health requirements for staff and public liability insurance. Evidence: During the inspection, the licensing inspector reviewed documentation that is given to parents and guardians. The information reviewed did not contain information describing physical facilities, enrollment capacity, health requirements for staff and public liability insurance.
Plan of Correction:	We were not aware this information was required to be disclosed in writing. A disclosure form was given to management during the inspection. The form with the required information will be completed and included in the information distributed to the parents and guardians.
Standard #:	63.2(17)-1716-B-3
Description:	Based on a review of 10 staff records and interview, the center did not ensure there was at least one staff member present that had been trained to conduct daily simple health screenings to exclude children as necessary. Evidence: The staff records did not include documentation of training to conduct daily simple health screenings. The licensing inspector asked members of management if the center had a procedure for ensuring that a daily simple health screening and exclusion of sick children is implemented. Staff stated that sick children are excluded, but that no staff had been trained on screening for illness at this point.
Plan of Correction:	We will have a physician conduct a daily health screening training with the staff during the September staff meeting.
Standard #:	63.2(17)-1716-B-5
Description:	Based on observation, the center did not ensure all areas of the premises accessible to children were free of obvisious injury hazards. Evidence: A crib was located against the wall in the Infant II classroom. The wall had areas of peeling paint that was accessible to the infant placed in the crib.
Plan of Correction:	The crib was moved during the inspection. A poster will be placed over the peeling paint until the area is repaired and painted.
Standard #:	63.2(17)-1720.1-A
Description:	Based on review of 10 staff records, one record did not contain the required updated background checks. Evidence: The record for Staff #7 (hire date: 07/21/08) contained a central registry finding dated 11/06/08 and a sworn statement dated 08/30/2011. Effective July 1, 2017, staff at all religiously exempt child day centers must repeat background checks every five years.
Plan of Correction:	We were not aware that background checks are now required to be updated at least every five years. We will audit all of our staff records and ensure all background checks are updated as required. Proof will be submitted to the licensing inspector within 10 days as evidence of compliance.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on review of 10 staff records and interview, the center did not obtain satisfactory results of the finger-print based national criminal background check for four staff prior to employment. Evidence: 1. The record for Staff #2 (hire date 11/26/18) did not contain satisfactory results of the finger-print based national criminal background check 2. The record for Staff #3 (hire date 10/29/18)) contained satisfactory results of the finger-print based national criminal background check dated 10/31/18. 3. The record for Staff #4 (hire date 12/06/18) contained satisfactory results of the finger-print based national criminal background check dated 06/06/19. 4. The record for Staff #5 (hire date 03/18/19) contained satisfactory results of the finger-print based national criminal background check dated 04/05/19.
Plan of Correction:	We did not realize the results of the finger print based background checks were required to be obtained before staff began working. In the future, we will not allow staff to begin work until the results of the criminal record check are obtained.