VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Grace Covenant Presbyterian Church
1617 & 1627 Monument Avenue
Richmond, VA 23220
(804) 213-0200

VDSS Contact: Molly Muscat (804) 588-2367

Inspection Date: Jan. 26, 2024

Complaint Related: No

Areas Reviewed:

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

Comments:

An unannounced code compliance inspection was initiated on 01/26/24. The inspector was on site on 01/26/24 from approximately 10:30 am until 01:30 pm. There were 77 children present, ranging in ages from four months to five years, with 16 staff supervising. The children were observed playing outside, getting diapers changed, and preparing for and eating lunch. Staff were observed having positive interactions with the children. All areas of the facility including classrooms, kitchen, hallways, outdoor play area, and bathrooms were inspected. Eight children's records and eight staff records were reviewed. 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. Please complete the plan of correction and ?date to be corrected? for each violation cited on the violation notice, sign, and return it to me within 5 business days from today, 02/15/2024. Please specify how the deficient practice will be or has been corrected. 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 preventative measure(s).

Violations:

Standard #:	22.1-289.031-B-1
Description:	Based on observation, the center failed to establish and implement procedures to ensure that staff and children wash their hands after diapering. Evidence: Staff #2 was observed changing a child's diaper. Staff #2 did not wash her hands or the child's hands after the diaper change.
Plan of Correction:	Staff are and will be closely monitored to ensure proper diaper changing procedures are followed by each and every staff member. This is and will be spoken more about during training and orientation of staff. Each staff not following proper diaper changing procedures will be written up. These observations will be done by the Assistant Director.
Standard #:	22.1-289.031-B-7
Description:	Based on interview, the center failed to ensure that all incidents involving serious physical injury to or death of children attending the child day center are reported to the Superintendent. Reports of serious physical injuries, which shall include any physical injuries that require an emergency referral to an offsite health care profession or treatment in a hospital, shall be submitted annually. Evidence: 1. Interviews and documentation review revealed that on 04/04/23 child #1 sustained an injury that required an outside medical emergency referral to an offsite health care profession. 2. Interviews with administration revealed that the center did not report this injury to the Superintendent annually because they were not aware that this was a requirement. 3. The last annual filing packet was submitted by the religious institution on 10/24/23 and additional filing documentation was submitted on 11/30/263, 12/6/23, 12/21/23, and 01/17/24. The documentation did not include documentation of a child requiring outside medical treatment.
Plan of Correction:	GCCDC Admin team will continue recording and documenting any and all injuries sustained at GCCDC facilities. Furthermore, will begin to report any and all serious physical injuries to the Superintendent. GCCDC will begin to keep incident reports based on birthdays and file according to birthday and age range. If a child sustains a serious physical injury at GCCDC and requires outside medical attention, the Admin team will obtain documents from parent about summary visits. Staff in each classroom will now be required to file their incident reports by each Friday of each week. Operations Manager will be in charge of signing and filing those reports under the supervision of the Director.
Standard #:	22.1-289.035-A
Description:	Based on record review, the center failed to obtain the results of a fingerprint based national criminal record search every five years. Evidence: The record for staff #5, date of employment 12/17/18, contained fingerprint results dated 12/11/18. An updated fingerprint based criminal record check was due on or before 12/11/2023.
Plan of Correction:	National finger-print background check will be completed before start date and redone every 5 years. Each year, the Admin team will list everyone who needs a new background check and will ensure those staff receive and complete valid checks. Director will be in charge of these reviews and corrections once a year.
Standard #:	22.1-289.035-B-2
Description:	Based on a review of eight staff records, the center did not ensure one staff had satisfactory results of the fingerprint-based national criminal background check prior to employment. Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #7, employed on 08/08/22, was dated 10/17/22.
Plan of Correction:	National finger-print background check will be completed before start date. Every 6 months, the Admin team will ensure staff files are valid and in line with VA Licensing code. Director will be in charge of these reviews and corrections.
Standard #:	8VAC20-770-40-D-2
Description:	Repeat Violation Based on record review, the center failed to obtain a sworn statement before the first day of employment and the results of a central registry background check within 30 days of employment. Evidence: 1. The record for staff #2, date of employment 12/21/23, contained a sworn statement dated 01/04/24. 2. The record for staff #6, date of employment 06/01/22, contained the results of a central registry check dated 01/07/23. 3. The record for staff #7, date of employment 08/08/22, did not contain the results of a central registry search.
Plan of Correction:	Staffing files will be maintained and ensured all documents will be completed before start date. GCCDC Admin team will ensure all staffing documents have the correct dates and correct background checks before staff officially starts at GCCDC. Central Registry's will be filled out during the hiring process and will be sent off before start date. Every 6 months, the Admin team will ensure Central Registries are valid and in line with VA Licensing code. Director will be in charge of these reviews and corrections.