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St. Andrew Lutheran Church
14640 Soucy Place
Centreville, VA 20120
(703) 266-7744

VDSS Contact: Mahrukh Aziz (571) 835-4718

Inspection Date: Sept. 29, 2022

Complaint Related: No

Areas Reviewed:
22.1 Background Checks Code; carbon monoxide detectors
54.1-3408 Must be MAT Certified.
63.2 Child Abuse & Neglect
22VAC40-191 Background Checks for Child Welfare Agencies

Technical Assistance:
Technical assistance was offered related to: Bathroom supervision; medications; and staff records including background checks. Information related to trainings for staff was also emailed to the program.

The center demonstrated compliance related to the installation of a carbon monoxide detector.

Comments:
An unannounced code compliance inspection was conducted on 9/29/22 from10am to 11:15 am. There were 47 children in direct care and supervision of 11 staff members. The children were observed engaged in various structured activities such as coloring, playing outdoors and circle time. Medications, 3 staff and 3 children's records were reviewed. Center postings required for exemption were posted. The information gathered during the inspection determined non compliance with applicable code sections. For any questions related to this inspection, please contact me at 571-835-4718 or mahrukh.aziz@doe.virginia.gov.

Violations:
Standard #: 22.1-289.035-B-2
Description: Based on records review and staff interview, the center did not obtain results of a fingerprint based criminal history search for staff before the first day of service.
Evidence:
1. Staff # 1 stated that Staff # 2 worked as a substitute staff in 2018, on an as-needed basis.
2. Staff # 2's fingerprint results were obtained on 9/27/19.

Plan of Correction: Fingerprints will be obtained before the first day of employment.

Standard #: 8VAC20-770-40-D-2
Description: Based on records review and staff interview, the center did not obtain for a volunteer, a complete Sworn Disclosure Statement (SDS) before the first day of service; and the results of a central registry search within 30 days of service.
Evidence:
1. Staff # 1 stated that in 2018 Staff # 2 worked at the center as a substitute staff on an as-needed basis. Staff # 1 stated in an email that a substitute staff member is used help with the floater position duties.
2. Staff # 2's SDS was not obtained until 9/19/19.
3. Staff # 2'sVA central registry results were obtained on 11/8/19, and not within 30 days of service.

Plan of Correction: Staff background checks will be obtained within the required timeframe.

Disclaimer:

A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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