VIRGINIA DEPARTMENT OF SOCIAL SERVICES

St. Luke's United Methodist Church
300 Ella Taylor Road
Yorktown, VA 23692
(757) 898-3017

VDSS Contact: Christine Mahan (757) 404-0568

Inspection Date: Oct. 3, 2019

Complaint Related: No

Areas Reviewed:

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

Comments:

An unannounced monitoring inspection was conducted on October 3, 2019 from approximately 9:45 am-1:30pm. Upon arrival to the facility, there were 54 children present with 12 staff members. The children were observed during circle time, in the art & library resource rooms and playing in the gymnasium. Twelve staff records were reviewed. Six rooms, the playground, the gymnasium, the fellowship hall and the chapel were observed. The center does not offer transportation.

Violations:

Standard #:	22VAC40-191-40-D-2
Description:	Based on record review, in 12 of 12 staff records reviewed, the center did not ensure that staff have a completed sworn statement before employment and results of a Search of the Central Registry within 30 days of employment. Evidence: The Director of Children's Ministries confirmed that the center did not have a completed sworn statement or Central Registry results for the following staff: Staff #11 and Staff #12-hired in 2007 Staff #3 and Staff #5-hired in 2011 Staff #6 and Staff #8-hired in 2015 Staff #1 and Staff #10-hired in 2016 Staff #2, Staff #4, Staff #7 and Staff #9-hired in 2017
Plan of Correction:	All staff will receive paperwork for their sworn statements. We will submit the Central Registry results once they are complete.
Standard #:	63.2(17)-1716-A
Description:	Based on inspection of the facility, the center did not ensure to post the fact that the facility is exempt from licensure in a visible location on the premises. Evidence: The Director of Children's Ministries confirmed that the facility had not posted the fact that it is exempt from licensure in a visible location on the premises.
Plan of Correction:	The Director of Children's Ministries will post religious exempt documentation information outside of the Director's Office.
Standard #:	63.2(17)-1716-A-6
Description:	Based on inspection of the facility and staff interview, the center had not described all required aspects of the child day center's operations in a written statement to the parents or guardians of the center and made available to the general public. Evidence: The Director of Children's Ministries confirmed that the following information had not been provided in writing to the parents/guardians and made available to the general public: physical facilities, enrollment capacity and public liability insurance
Plan of Correction:	The Director of Children's Ministries will create an addendum that will extensively explain the enrollment capacity for the preschool, our liability insurance coverage information and the physical facilities of the preschool inside of the church building.
Standard #:	63.2(17)-1716-B-7
Description:	Based on inspection of the facility and staff interview, the center did not establish and implement procedures to ensure that all requirements were maintained for reports of serious injury or death of children attending the child day center. Evidence: The Director of Children's Ministries confirmed that the center had not established and implemented the following procedures: 1. Ensuring that all incidents involving serious physical injury to or death of children attending the child day center are reported to the Commissioner. 2. Reports of serious physical injuries, which shall include any physical injuries that require an emergency referral to an offsite health care professional or treatment in a hospital, shall be submitted annually. 3. Reports of deaths shall be submitted no later than one business day after the death occurred.
Plan of Correction:	An addendum will be added to the staff handbook that clearly outlines policies and procedures on how to report serious injuries to the Commissioner.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on record review, in 12 of 12 staff records reviewed, the center did not ensure that staff submit to fingerprinting and obtain results. Evidence: The Director of Children's Ministries confirmed that the center had not obtained fingerprint results for the following staff: Staff #11 and Staff #12-hired in 2007 Staff #3 and Staff #5-hired in 2011 Staff #6 and Staff #8-hired in 2015 Staff #1 and Staff #10-hired in 2016 Staff #2, Staff #4, Staff #7 and Staff #9-hired in 2017
Plan of Correction:	Staff will receive all information and procedures to obtain fingerprints.