VIRGINIA DEPARTMENT OF SOCIAL SERVICES

House of Genesis
3118 Cofer Road
Richmond, VA 23224
(804) 233-6425

VDSS Contact: Florence Martus (804) 389-0157

Inspection Date: June 14, 2023

Complaint Related: No

Areas Reviewed:

8VAC20-790 Administration 8VAC20-790 Staff Qualifications & Training 8VAC20-790 Physical Plant 8VAC20-790 Staffing & Supervision 8VAC20-790 Special Care Provisions & Emergencies 8VAC20-790 Special Services

Technical Assistance:

n/a

Comments:

An unannounced complaint inspection was initiated on Tuesday, June 6, 2023, and concluded on Wednesday, July 12, 2023. The complaint was regarding allegations of non-compliance with staff to child ratio and supervision. On June 14, 2023, the inspector as on-site from approximately 3:00pm until 4:25pm. There were 21 children in care and one staff present at the center. The inspector reviewed documentation and conducted observations and conducted interviews on-site. Additional documentation was requested and reviewed remotely. On July 11, 2023, the inspector was on-site from approximately 9:50am until 1:00pm conducting follow-up activities and interviews. A total of two staff records were reviewed. Based on the information gathered during the investigation, the preponderance of evidence supports the allegation, therefore the complaint is determined to be valid. Additional violations were discovered, and violations were documented on the violation notice issued to the program. Please complete the `plan of correction? and `date to be corrected? for each violation cited on the violation notice and returned it to me within five business days from today. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	8VAC20-790-520-G
Description:	Based on a review of documentation and interviews, the vendor, a religiously exempt child day center that is exempt from licensure in accordance with 22.1-289.031 of the Code of Virginia, did not ensure to be in compliance with all requirements of 22.1-289.031. Evidence: 1) On 06/05/23, from approximately 4:00pm to 4:22pm, there was not a person present at the child day center that was trained and certified in first aid and cardiopulmonary resuscitation (CPR). The record of daily attendance indicated there were 16 children in care on 06/05/23 at 4:00pm. 22.1-289.031.A.8 requires a person trained and certified in first aid and cardiopulmonary resuscitation (CPR) will be present at the child day center whenever children are present or at any other location in which children attending the child day center are present. 2) On 06/05/23, Parent #2 received a phone call from Staff #1 requesting the parent to stay with the children at the center while Staff #1 left the center to pick up two children from a school nearby. Parent #2 agreed and was expected to be alone with children. Parent #2 arrived at the center at approximately 4:07pm and Staff #1, the only staff person on duty, was no longer at the center. It was determined that Staff #1 left 16 children with Parent #1 and Parent #2 from approximately 4:00pm to 4:22pm. Staff #1 acknowledged she asked both parents to stay at the center while she ran out to pick up two children from a school nearby. Parent #1 and Parent #2 had not obtained the required background checks. 22.1-289.031.5.b requires that the center is in compliance with the requirements of section 22.1-289.039 relating to background checks. Any child day center that is exempt from licensure pursuant to 2.1-289.031 shall require all applicants for employment, employees, applicants to serve as volunteers, and volunteers and any other person who is expected to be alone with one or more children enrolled in the child day center to obtain a background check in accordance with 22.1-289.035.
Plan of Correction:	Per the Vendor: "there will always be staff present who is trained in First Aid and CPR training."
Standard #:	8VAC20-790-530-B
Description:	Based on a review of documentation and interviews, the vendor did not maintain a written hard copy record of daily attendance that documents the arrival and departure of each child in care as it occurs. Evidence: The following was determined after review of the written record of daily attendance for 06/05/23 - 1) The time of departure of Child #19 and Child #22 was not documented. 2) The time of arrival and departure of Child #16 was not documented. 3) During interview, Staff #1 confirmed Child #16 was present at the center on 06/05/23, but the time of arrival and departure were not noted as required. Staff #1 confirmed the time of departure for Child #19 and Child #22 was not noted as required. 4) On 06/05/23, Child #14 and Child #15 arrived at the center with Staff #1 after approximately 4:22pm. The center?s written record of daily attendance did not document the children?s arrival or departure. The children were not listed as being present on 06/05/23. During interview, Staff #1 acknowledged Child #14 and Child #15 were present at the center in the afternoon of 06/05/23.
Plan of Correction:	Per the Vendor: "parents will be reminded to sign in and out including the times of arrival and departure."
Standard #:	8VAC20-790-550-2-a
Description:	Based on a review of two staff records and interview, the vendor did not ensure one staff had the satisfactory results of the Virginia Child Protective Services Central Registry check within 30 days of the staff beginning employment. Evidence: 1) The record of Staff #2, employed on 05/09/23, did not contain the results of the Virginia Child Protective Services Central Registry check. 2) During interview, Staff #1 reported a request of the search of the central registry was mailed, but the results have not been received to date.
Plan of Correction:	Per the Vendor: "[Staff #2]'s Central Registry background check arrived on July 19, 2023. Will send request within first 7 days of them starting, and within 30 days. If not received will call the office of investigation"
Standard #:	8VAC20-790-560-A
Description:	Based on a review of documentation, the vendor did not ensure one staff was evaluated by a health professional and was issued a statement that the individual is determined to be free of communicable tuberculosis (TB) within the required timeframe. Evidence: The TB screening in the record of Staff #2, employed on 05/09/23, was completed on 02/05/23. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
Plan of Correction:	Per the Vendor: "TB questionnaire in lieu of test. Dr. will sign off on it (TB) Screening form)"
Standard #:	8VAC20-790-600-I
Description:	Based on a review of documentation and interviews, the vendor did not ensure there shall be at least one staff on duty who has obtained within the last three years instruction in performing a daily health observation of children. Evidence: 1) The record of daily attendance indicated there were 16 children in care on 06/05/23 at 4:00pm. 2) During interviews, it was determined that there were no staff on duty on at the center from 4:00pm to approximately 4:22pm on 06/05/23.
Plan of Correction:	Per the Vendor: "New staff will be trained online with child abuse and neglect training."
Standard #:	8VAC20-790-670-C-6
Description:	Based on a review of documentation, interviews, and observation, the vendor did not ensure when a group of children receiving care includes children from different age brackets, the age of the youngest child in the group shall be used to determine the staff-to-children ratio that applies to that group. Evidence: 1) A review of the center?s record of daily attendance and verification of the ages of children present showed there were a total of 19 children in care on 06/05/23. It was determined that Child #9 (6-months-old) was the youngest child present and was dropped off at 7:30am. There was a total of five other children at the center when Child #6 was dropped off and 13 additional children arrived between 7:45am and 2:05pm. The children?s ages ranged from 6 months to 9 years of age. 2) On 06/14/23 at approximately 3:00pm, the inspector observed 21 children (6 months to 9 years of age) in care with only Staff #1 supervising. 3) During interview, Staff #1 acknowledged she was the only staff member present at the center on 06/05/23 and on 06/14/23. Staff #1 reported Staff #2 was scheduled to be at the center at 1:30pm both days but was not able to be there. The staff-to-child ratio that applied to the group was one staff member to four children based on the age of the youngest child present.
Plan of Correction:	Per the Vendor: "This ratio is being corrected. I am currently in the process of hiring new staff as we speak. I have begun the interview process and have received background checks and fingerprinting. I am awaiting the physical examination and TB results. I understand the ratio requirements for students and staff."
Standard #:	8VAC20-790-670-D-1
Description:	Based on a review of documentation, interviews, and observation, the vendor did not ensure the maximum group size requirements were maintained when children were in care. Evidence: 1) A review of the center?s record of daily attendance and verification of the ages of children present showed there were a total of 19 children in care on 06/05/23 with only Staff #1 supervising. The children?s ages ranged from 6 months to 9 years of age and were all combined in one group. 2) On 06/14/23 at approximately 3:00pm, the inspector observed 21 children combined in one group, 6 months to 9 years of age, in care with only Staff #1 supervising. 3) During interview, Staff #1 acknowledged she was the only staff member supervising children on 06/05/23 and on 06/14/23. Staff #1 reported Staff #2 was scheduled to be at the center at 1:30pm both days but was not able to be there. The maximum group size is applied to the youngest child in the group and is applicable to the entire group. The maximum group size for children birth to two years is 12 children.
Plan of Correction:	Per the Vendor: "This ratio is being corrected. I am currently in the process of hiring new staff as we speak. I have begun the interview process and have received background checks and fingerprinting. I am awaiting the physical examination and TB results. I understand the ratio requirements for students and staff."
Standard #:	8VAC20-790-670-H
Description:	Based on a review of documentation and interviews, the vendor did not ensure children less than 10 years of age shall always be within actual sight and sound supervision of staff. Evidence: 1) Collateral interviews indicated that on 06/05/23, Staff #1 left two parents to care for 16 children without supervision of staff from approximately 4:00pm until 4:22pm. 2) A review of the center?s record of daily attendance for 06/05/23 showed there were 16 children in care at 4:00pm when Staff #1 left the premises. The ages of the children ranged from 6 months to 9 years of age. 3) Staff #1 stated that on 06/05/2023 she asked two parents to stay at the center while she ran out to pick up two children from a school nearby. 4) According to interviews, Parent #1 was alone with 16 children from 4:00pm until approximately 4:07pm when Parent #2 arrived. Parent #1 left the center at 4:07 with 2 children. Parent #2 was alone with 14 children from 4:07pm until approximately 4:22pm when Staff #1 returned to the center. It is estimated the children were without actual sight and sound supervision of staff for approximately 22 minutes.
Plan of Correction:	Per the Vendor: "The children are always within site of day care staff. I received an emergency call from the school to pick up 3 children as I am listed as the emergency contact pick up. I was told by the school that if the children were not picked up right away that the Police, Social Services and Child Protective Services would be called. I immediately phoned the parent to notify her. The parent told me that she was in Mechanicsville getting replacement tires. In an effort to prevent that, as the school was 5 minutes distance, I asked two parents who were there if they could sit with them until I returned. I contacted the parent and through love and prevention I made a decision out of haste. What I did was to prevent children from being removed from their parents? care based on the threat from the school. This was a one-time incident in response to an emergency situation. This will not happen again. I understand the risk posed to the children. This has been corrected and will not happen again."
Standard #:	8VAC20-790-820-E
Description:	Based on observations and interview, the vendor did not ensure prepared infant formula shall be refrigerated, dated, and labeled with the child's name if more than one infant is in care. Evidence: 1) On 06/14/23, the inspector observed three bottles on the kitchen countertop. The bottles were not labeled or dated. 2) During interview, Staff #1 reported the bottles were prepared formula and acknowledged they were not labeled with the child?s name. There were four infants in care on 06/14/23.
Plan of Correction:	Per the Vendor: "bottles are now labeled with date and full name of child. All bottles are kept refrigerated."