VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Trisha Shanholtz
120 Refuge Church Road
Stephens city, VA 22655
(540) 327-3603

Current Inspector: Beth Orebaugh (540) 847-9173

Inspection Date: Sept. 14, 2023

Complaint Related: No

Areas Reviewed:

8VAC20-800 Administration 8VAC20-800 Personnel 8VAC20-800 Household Members 8VAC20-800 Physical Health of Caregivers and Household members 8VAC20-800 Caregiver Training 8VAC20-800 Physical Equipment and Environment 8VAC20-800 Care of Children 8VAC20-800 Preventing the Spread of Disease 8VAC20-800 Medication Administration 8VAC20-800 Emergencies 8VAC20-800 Nutrition 8VAC20-800 Transportation 8VAC20-800 Nighttime Care 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 54.1 Provider must be MAT certified to administer prescription medication.

Comments:

A monitoring inspection was initiated on 09/14/2023 and concluded on 09/14/2023. There were 5 children present, ranging in ages from 1 years to 4 years, with 2 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 5 child records and 2 staff records were reviewed. Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	8VAC20-800-800-B
Description:	Based on review of documents, the provider did not ensure the emergency plan at least annually be reviewed, updated, and documented in writing each review and update to the emergency plan. Evidence: 1. The emergency plan had not been updated or documented that it had been updated since 2019. 2. The provider confirmed that it has not been reviewed or updated since 2019.
Plan of Correction:	I will be sure to do that later today and then annually. I will also be sure to document the information of when reviewed and updated.
Standard #:	8VAC20-800-680-A
Description:	Based on observation, the provider did not ensure that all caregivers washed their hands with liquid soap and warm running water after diapering a child. Evidence: 1. LI observed Staff 2 conduct a diaper change and Staff 2 did not wash their hands after the diaper change was completed.
Plan of Correction:	I will retrain on diapering and make sure we do all the steps.