VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady of the Blessed Sacrament Church
207 W. Euclid Boulevard
West point, VA 23181
(804) 843-4177

VDSS Contact: Florence Martus (804) 389-0157

Inspection Date: Feb. 28, 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

Technical Assistance:

n/a

Comments:

A code compliance inspection was initiated on Tuesday, February 28, 2023 and concluded on March 7, 2023. On February 28, the inspector was on site from 10:50am to approximately 12:25pm. There were 24 children in attendance with four staff directly supervising. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility including classrooms, hallways, the outdoor play area, and bathrooms were inspected. Five children's records and six staff records were reviewed. Additional documentation was submitted to the inspector electronically on 03/01/2023 and 03/07/2023. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on a review of six staff records, the center did not ensure one staff had the satisfactory results of the fingerprint-based national criminal background check within the required timeframe. Evidence: The fingerprint-based national criminal background check in the record of Staff #5, employed 07/13/22, was dated 08/22/22. The results of the fingerprint-based national background check are required to be obtained prior to employment.
Plan of Correction:	Per the Center: "The violations cited have since been fixed. All sworn statements have been signed, all fingerprinting is complete. All necessary documents for each employee have been thoroughly checked and on file here at the office of the church. Per the one employee staff #5 that was said to have been employed on 7/13 and central registry not completed until 8/33, please know that staff did not work with any children during that period. The staff was only hired on the July date so she would complete her Virtus child safety training through the Diocese prior to high school starting in August since she is a high school student. She did not actually work at the program with children until 8/22/22. We will, however, make sure in the future not to put a start date without knowing the employee has completed the fingerprinting. We just never know how long that process will take and we have other training that needs to be completed before the employee can start. We will work to make this process better. Myself, [Director] and [Office Manager], the officer manager of the church, will both be more attentive to and responsible for making sure all records are on file and paperwork completed. We both feel that paperwork was simply missing that had already been completed. We will make sure to routinely check files in the future to avoid this happening again."
Standard #:	8VAC20-770-40-D-2
Description:	Based on a review of six staff records and interview, the center did not ensure two staff had a complete sworn statement or affirmation or the results of the central registry check within the required timeframe. Evidence: 1) The record of Staff #4, employed 08/31/21, did not contain documentation of a completed sworn statement or affirmation before employment. 2) The record of Staff #5, employed 07/13/22, did not contain documentation of a completed sworn statement or affirmation before employment. The search of the central registry check in the record of Staff #5 was dated 08/22/22. The search of the central registry check is required to be obtained within 30 days of employment. 3) During interview, management reported the original sworn statements signed by Staff #4 and Staff #5 could not be located. The staff completed a new sworn statement on 03/01/23.
Plan of Correction:	Per the Center: "The violations cited have since been fixed. All sworn statements have been signed, all fingerprinting is complete. All necessary documents for each employee have been thoroughly checked and on file here at the office of the church. Per the one employee staff #5 that was said to have been employed on 7/13 and central registry not completed until 8/33, please know that staff did not work with any children during that period. The staff was only hired on the July date so she would complete her Virtus child safety training through the Diocese prior to high school starting in August since she is a high school student. She did not actually work at the program with children until 8/22/22. We will, however, make sure in the future not to put a start date without knowing the employee has completed the fingerprinting. We just never know how long that process will take and we have other training that needs to be completed before the employee can start. We will work to make this process better. Myself, [Director] and [Office Manager], the officer manager of the church, will both be more attentive to and responsible for making sure all records are on file and paperwork completed. We both feel that paperwork was simply missing that had already been completed. We will make sure to routinely check files in the future to avoid this happening again."