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CDI HS Serving Frederick & Clarke Counties, VA Poux Center
444 Shady Elm Road
Winchester, VA 22602
(540) 869-1558

Current Inspector: Maureen Gallagher-McLeod (540) 430-9259

Inspection Date: Dec. 12, 2018

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
22VAC40-191 Background Checks (22VAC40-191)
63.2(17) License & Registration Procedures
63.2 Facilities & Programs.

Technical Assistance:
We reviewed the requirements for emergency practice drills, posting information, and child abuse registry checks for staff. The risk assessments for violations were provided. We reviewed sight supervision procedures during transitions in the hall. Also, staff record requirements and options for record keeping systems were discussed.

Comments:
Thank you for your assistance during the unannounced monitoring inspection conducted from 10:40 AM to 3:30 PM. Today, there were twenty-eight children, ages three through five years, with four staff. I viewed program activities, daily routines, lunch, nutrition, diapering procedures, posted information, medication, injury records, emergency supplies and drill records, equipment, agency inspection reports, staffing, supervision, interactions with children, five records for children, seven staff records, staff qualifications, staff training, transportation, indoor and outdoor areas. We discussed sight supervision procedures during transitions in hallways. I viewed and measured the depth of new mulch in fall zones of playground equipment. The children have enjoyed a variety of planned group experiences of music, stories and art. Children have been provided choices for imaginative play and learning materials in classroom interest areas. Let me know if you need any assistance. 540/430-9259

Violations:
Standard #: 22VAC40-185-550-D
Description: Based on a review of the emergency evacuation drill records, and an interview with administrative staff, the center failed to implement monthly practice evacuation drills during each calendar month of operation. Evidence: There was documentation of evacuation practices for classroom A and classroom B for November 20, 2018. According to administrative staff, an evacuation drill was not conducted in October after the change in sponsorship of the program on October 15, 2018.

Plan of Correction: The administrative staff will make sure evacuation practices are conducted during all calendar months the program is in operation. The administrative staff will review the requirements for implementing emergency drills with the teaching staff.

Standard #: 22VAC40-191-60-C-2
Description: Based on a review of seven records for staff, and interviews with administrative staff and an employee of the Office of Background Investigations, the center failed to obtain Virginia child abuse registry clearances within thirty days of employment for four staff. Evidence: The results of the searches of the central registry were not in the files of staff member 1, 2, 4 and 5. Staff member 1 began employment on October 29, 2018 and a copy of the request form was signed by the employee on October 24, 2018. Staff member 2 began employment on October 15, 2018 and a copy of a request form was signed on October 9, 2018. Staff member 4 began employment on October 15, 2018 and a copy of the request form was signed on September 29, 2018. Staff member 5 began employment on October 15, 2018 and a copy of the request form was signed on September 29, 2018. An error letter dated October 23, 2018 was sent from the agency about missing information on the request form for staff member 5. Administrative staff indicated the form was corrected and mailed to the agency. Administrative staff indicated there was not documented effort to contact the agency in Richmond when the required background checks were not received within thirty days. Administrative staff immediately called the Office of Background Investigations and both the administrative staff and the licensing inspector were told that the findings were sent by email which stated there was not a finding in the registry. The agency representative said their office has logged out of the individual records so it will take time to generate a new qualifying letter to be sent to the center.

Plan of Correction: The designated administrative staff will make sure the missing Virginia central registry findings are obtained, viewed and filed. Copies of the received background checks for the four staff members will be sent to the licensing inspector to demonstrate compliance. The administrative staff will review all records to make sure they received and reviewed all required background checks. A system for tracking background check request dates and receipt of the information will be developed and used so that all required information is obtained in a timely manner.

Standard #: 22VAC40-80-120-E-2
Description: Based on a review of posted information, and an interview with administrative staff, the center did not post the findings of the most recent licensing inspection of the facility. Evidence: The violation notice was not posted in the entrance area or near the license on the bulletin board in the hallway. When asked about the location for posting the October inspection findings, a staff member indicated that the violation notice was kept in an office binder.

Plan of Correction: Administrative staff immediately posted the violation notice from the October inspection report. The most recent inspection findings will be posted near the license at all times.

Standard #: 63.2(17)-1720.1-B-3
Description: Based on a review of seven records for staff, and interviews with administrative staff, the center failed to obtain a copy of the results of the child abuse registry, or any equivalent registry, from the state that one staff member indicated living in during the past five years. Evidence: Staff member 5 began employment with the new sponsor of the center on October 15, 2018 and there was documentation on the Sworn Statement or Affirmation as well as other records about residence that another state has been lived in during the preceding five years. There was not a child abuse registry finding from the designated state in the file. There was a copy of the request form with documentation that it was mailed on October 10, 2018. There was not any documentation that an inquiry with the out of state agency was conducted when the findings were not received within forty-five days.

Plan of Correction: Administrative staff will follow-up with the inquiry made to the state agency and make sure the required background check is received. A copy of the out-of-state registry findings will be sent to the licensing inspector. The administrative staff will review all records to make sure they received and reviewed all required background checks. A system for tracking background check request dates and receipt of the information will be developed and used so that all required information is obtained in a timely manner.

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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