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Maria Teresa's Babies Early Enrichment Center
825 23rd Street
Arlington, VA 22202
(703) 979-2229

Current Inspector: Brenda Kuhlman (703) 304-9609

Inspection Date: May 24, 2018

Complaint Related: Yes

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
63.2 Licensure and Registration Procedures
22VAC40-191 Background Checks (22VAC40-191)

Technical Assistance:
- Employees can not be on the premises without record check eligibility letter on file. - Additional lead qualified staff required in the infant room based on staffing and child ratios. - Document follow-up for central registry results not received by 30th day of employment for new staff.

Comments:
An unannounced complaint investigation was conducted on 5/24/2018 and 6/7/2018 in response to a complaint made to our office alleging that there are not enough lead qualified staff. A joint investigation was conducted with a local agency. Based on classroom observations, interviews and records review, there is a preponderance of evidence to support the claim; therefore, the complaint is deemed valid. Areas of noncompliance are documented on the violation notice. Additional violations not related to the complaint are also cited. If you have any questions, please contact me at Ivaco.Clarke@dss.virginia.gov or at 571-835-5505.

Violations:
Standard #: 22VAC40-185-160-A
Complaint related: No
Description: Based on a review of records, 2 out of 22 staff members did not submit documentation of a negative tuberculosis screening completed within 12 months prior to or 21 days after employment. Evidence: A tuberculosis screening for Staff #8 [date of hire: 5/21/2018] was obtained 2/6/2017, approximately 15 months prior to employment. There was no documentation of a tuberculosis screening available for Staff #17 [date of hire: 4/11/2018].

Plan of Correction: A negative tuberculosis screening for both staff has been completed and is on file

Standard #: 22VAC40-185-160-C
Complaint related: No
Description: Based on a review of records, documentation of subsequent tuberculosis screenings [every two years from the date of the initial screening] for 1 staff member was not available at the time of the inspection. Evidence: On 6/7/2018, the most recent tuberculosis screening available for Staff #4 was obtained 9/10/2014.

Plan of Correction: Staff has a negative tuberculosis screening completed on file since 10/30/2017. (SIP)

Standard #: 22VAC40-185-70-A
Complaint related: No
Description: Based on record review, 4 out of 22 staff records did not include all required documentation. Evidence: 1. On 5/24/2018, the record for Staff #1 was missing an emergency contact, documentation of 2 required references prior to employment and documentation of education, and experience required by the job position. 2. The record for Staff #8 was missing documentation of 2 references. 3. On 6/7/2018 it was determined that the record for Staff #2 was missing documentation of 1 of 2 required references. 4. On 6/7/2018, the previous date of separation of employment from CDC for Staff #4 was not documented [date of rehire: 10/5/2017]. 5. On 6/29/2018, the record for Staff #21 was missing documentation of 2 references.

Plan of Correction: Corrected emergency contact; References and education are on file; Corrected documentation of references on file; Documented previous date of separation

Standard #: 22VAC40-185-210-A
Complaint related: No
Description: Based on review, 2 of 5 staff identified as program leaders did not meet the qualifications for the stated position. Evidence: 1. In Classroom A, Staff #1 was identified as the program leader; however, there was no documentation of education [diploma or transcripts] or work related experience on file. 2. In Classroom D, Staff #5 was identified as a program leader; however, at date of hire [4/6/2018] there was no relevant work experience documented in the file to qualify them for the position. Education documents on-file for Staff #5 were from outside the United States and no translation and equivalency were on-file.

Plan of Correction: Official transcripts and work experience are documented on file.

Standard #: 22VAC40-185-240-A
Complaint related: No
Description: Based on a review of records and discussion with staff, 2 out of 22 staff records were missing documentation of receiving the required training by the end of their first day of assuming job responsibilities. Evidence: 1. On 5/24/2018 documentation of orientation training was not available at the time of inspection for Staff #8. [The Director reported that the date of hire for Staff #8 was 5/21/2018; however, staff scheduling sign-in sheets document that the staff member was working as early as 5/17/2018.] 2. On 6/29/2018, there was no documentation of orientation training in the file for Staff #21 [date of hire: 6/21/2018].

Plan of Correction: Corrected; We will make sure that every employee had the orientation on file.

Standard #: 22VAC40-185-340-D
Complaint related: No
Description: Based on observations, interviews and records review, at least one staff member who qualifies as a program leader or director was not regularly present in each grouping of children. Such a program leader shall not supervise more than two aides. Evidence: 1. On 5/24/2018 and 6/7/2018, it was directly observed that no staff with program leader qualifications was present in Classrooms A, C or D. 2. On 6/7/2018, it was directly observed that Staff #2 [lead qualified] arrived at 11:13am and was observed supervising 4 aids [Staff # 11, #15, #16, #18] in Classroom F. 3. On 6/29/2018, no staff with program leader qualifications was present in Classroom B, D, E or F. 4 aids (Staff #12, #15, #18, #21) were observed in Classroom F.

Plan of Correction: We are waiting to verify qualifications of current lead teachers and we are waiting to fill a position.

Standard #: 22VAC40-185-350-E-2
Complaint related: No
Description: Based on observation, ratio requirements were not met [16 mons to 2 yrs; one staff/5 children]. Evidence: 1. On 5/24/2018, 7 children were observed in the care of 1 staff member in a toddler classroom [Classroom C]. 2. On 6/29/2018, 6 children were observed in the care of 1 staff member in a toddler classroom [Classroom E].

Plan of Correction: Staff instructed not to leave the group. (SIP)

Standard #: 22VAC40-185-350-E-3
Complaint related: No
Description: Based on observations made, it was determined that a 2's group did not maintain a 1:8 ratio for a period of time. Evidence: On 6/7/2018, the ration was observed to be 1:9, when one staff person left the classroom and went outside to the playground to get a child[the 10th child] that was left on the playground. The ratios were not maintained for approximately 1 minute.

Plan of Correction: Staff is instructed to keep all children together when going outside and coming back in and not to leave children with other groups even for one minute (outside or inside). (SIP)

Standard #: 22VAC40-185-560-N
Complaint related: No
Description: Based on observations made, it was determined that on 6/7/2018 children were walking while eating and drinking. Evidence: In Classroom D, children were observed being fed soup by staff while they were walking around the classroom. Children were observed climbing on chairs and 2 children were observed flipping over two tables. One child was observed walking and drinking from a sip cup for approximately 3 minutes.

Plan of Correction: We will be sure the children seat while they eat. Most of the time children act differently when they see people they are not familiar seeing. (SIP)

Standard #: 22VAC40-191-40-D-1-C
Complaint related: No
Description: Based on record review, 1 staff member record did not include a recent criminal history record check every three years. Evidence: The most recent criminal record check available at the time of inspection for Staff #9 was obtained 5/19/2014.

Plan of Correction: Corrected; Fingerprint check takes over criminal background check and is on file.

Standard #: 22VAC40-191-60-B
Complaint related: No
Description: Based on record review, 1 of 22 staff records did not include documentation of a completed Sworn Disclosure Statement (SDS) prior to the first day of employment. Evidence: The sworn statement for Staff #8 [date of hire: 5/21/2018 according to Director and 5/17/2018 per staff schedule record] was signed 5/25/2018. In addition, 3 out of 5 questions were not answered on the sworn statement.

Plan of Correction: Staff completed sworn statement on the same day; All new staff is required to have this completed correctly on the first day of employment. (SIP)

Standard #: 22VAC40-191-60-C-2
Complaint related: No
Description: Based on a review of records, the center failed to obtain central registry findings within 30 days of employment for 4 out of 22 staff members. Evidence: As of 6/7/2018, there were no central registry results on file for Staff #16 [date of hire: 4/9/2018], Staff #17 [date of employment: 4/11/2018], Staff #5 [date of hire: 5/7/2018] or Staff #11 [date of hire: 5/7/2018].

Plan of Correction: Copies of returned file registry to resubmit because the changed forms and were to expedite results. Contacted DSS staff.

Standard #: 22VAC40-80-120-A-7
Complaint related: No
Description: Based on observation, the facility did not operate within the terms of its license based on limitations set by the department within the context of the regulations. Evidence: Upon arrival on 6/7/2018], 30 children were observed outside in the larger fenced play area; however, a stipulation on the license limits the number of children outside in the larger fenced play area to 26 children at any one time.

Plan of Correction: This was an exception for the talent show the children were rehearsing and staff wanted to see interactions and logistic. The show was performed for all parents on June 28th and it was a great success. This is not an everyday occurrence. (SIP)

Standard #: 63.2-1720.1-B-2
Complaint related: No
Description: Based on record review and interview, the center failed to ensure that employees shall undergo a criminal history background check prior to employment. Evidence: 1. On 5/24/2018, there was no fingerprint background check on file for Staff #1 [observed working with children]. Director reported the staff member's date of employment was on that day [5/24/2018]; however, staff scheduling documentation states that the staff member was employed as early as 4/30/2018. 2. On 5/24/2018, there was no fingerprint background check on file for Staff #8 [observed working with children]. Director reported that the staff member's date of employment was 5/21/2018; however, staff scheduling documentation states that the staff member was employed as early as 5/17/2018. On 6/7/2018, fingerprint results remained missing for Staff #8. 3. There was no fingerprint background check on file for Staff #17 observed working with children [date of employment: 4/11/2018]. 4. On 6/29/2018, there was no fingerprint background check on file for Staff #21 observed working with children [date of hire: 6/21/2018].

Plan of Correction: For new staff, I send them to get fingerprints before they start. (SIP)

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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