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Welborne United Methodist Church
920 Maybeury Drive
Henrico, VA 23229
(804) 741-8771

VDSS Contact: Molly Muscat (804) 588-2367

Inspection Date: March 14, 2023

Complaint Related: No

Areas Reviewed:
22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
32.1 Report by person other than physician
54.1 Must be MAT Certified.
63.2 Child abuse and neglect
8VAC20-770 Background Checks
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services

Comments:
An annual monitoring inspection was initiated on 03/14/2023 and concluded on 03/14/2023. The inspector was on site at the center from 9:30am
to 11:35am. There were 76 children in care with 10 staff supervising. Interviews were held with staff throughout the inspection, and the inspector
interacted with children in each classroom when appropriate. The center?s playground and all classrooms were inspected today. Seven children?s
records and seven employee records were reviewed during this inspection. Information gathered during the inspection determined areas of noncompliance with applicable regulations or law, and violations were documented on the violation notice issued to the vendor.
If you have any questions regarding this inspection, please contact the licensing inspector at (804) 929-3771.

Violations:
Standard #: 22.1-289.035-A
Description: Based on record review, the facility failed to obtain repeat national criminal history search results for 5 of 7 staff within five years since the date of the last completed national criminal history search.
Evidence:
1. The record of staff #3 (employment date: 9/1/2013) had documentation of national criminal history search results dated 2/27/2018.
2. The record of staff #4 (employment date: 8/1/2017) had documentation of national criminal history search results dated 2/6/2018.
3. The record of staff #5 (employment date: 8/2001) had documentation of national criminal history search results dated 2/6/2018.
4. The record of staff #6 (employment date: 9/1/2011) had documentation of national criminal history search results dated 2/10/2018.
5. The record of staff #7 (employment date: 1/2001) had documentation of national criminal history search results dated 2/8/2018.

Plan of Correction: Will send staff to get fingerprinted in the next 7 days and proof in 10 days.

Standard #: 22.1-289.035-B-2
Description: Based on record review, the vendor did not ensure two of seven staff records contained
documentation of fingerprint based national criminal history search results prior to employment.
Evidence:
1. The record of staff #1 (employment date: 9/1/2021) had documentation of fingerprint based national criminal history search results dated 9/20/2021.
2. The record of staff #2 (employment date: 12/2/2022) had documentation of fingerprint based national criminal history search results dated 1/13/2023.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22.1-289.058
Description: Based on observation and an interview, the center did not ensure that the building serving
preschool aged children was equipped with at least one carbon monoxide detector.
Evidence:
The licensing inspector did not see a carbon monoxide detector installed in the center. The
center?s administrator stated that a carbon monoxide detector is not currently installed in
the building.

Plan of Correction: Will purchase a detector today and have it in school immediately.

Standard #: 8VAC20-770-40-D-2
Description: Based on record review, the provider did not ensure 3 of 7 staff records had documentation
of central registry results within 30 days of employment and a completed sworn statement
or affirmation prior to employment.
Evidence:
1. The record of staff #1 (employment date: 9/1/2021) did not have documentation of central
registry results or a completed sworn statement or affirmation.
2. The record of staff #2 (employment date: 12/2/2022) did not have documentation of central
registry results.
3. The record of staff #4 (employment date: 8/1/2017) did not have documentation of central
registry results.

Plan of Correction: Will have [staff # 1] fill out sworn disclosure today and will process central registry on portal in next 2 days.

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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