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Community Development Institute Head Start-Lancaster
36 Primary School Circle
Lancaster, VA 22503
(804) 462-5100

Current Inspector: Sharon Curlee (804) 662-9758

Inspection Date: May 22, 2019 and May 28, 2019

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.
22VAC40-191 Background Checks (22VAC40-191)
63.2(17) License & Registration Procedures

Comments:
An unannounced renewal inspection was conducted May 28, 2019 to determine the facilities compliance with licensing standards. The inspection was initiated at 9:30 am and concluded at 11:40 am. At the time of the inspector's arrival children were playing in centers that consisted of dress-up, kitchen, tablets and cash register. Staff and children counted money and reviewed numbers. Later children had bathroom breaks and washed their hands before heading lunch in the school cafeteria. In the cafeteria, tables were cleaned and staff assisted children with task such as opening milk cartons. Staff and children sat together and conversed. Today's lunch consisted of chicken salad, whole wheat crackers, potato wedges, fruit cocktail milk. Staff were observed interacting with the children in a positive manner. The classroom is equipped with age appropriate materials and supplies. The playground was inspected and found in compliance with licensing standards. The first aid kit and non-medical emergency supplies were inspected and found complete. All required information was posted on the parent bulletin board to include the License, last inspection notice, emergency numbers, daily schedule, evacuation maps, allergy list and menu. The inspector interacted with staff and children in care.

Emergency Information for three staff was reviewed on site along with the records of six children. Staff records were reviewed at the administrative office on May 22, 2019 from 12:00 pm until 4:00 pm.
Medications are administered by the elementary school nurse and stored in the school clinic. Staff on site have current MAT certification, CPR, First aid and daily health observation training.
The most recent evacuation drill was documented on 05/09/2019. The two required shelter-in-place drills were completed on 10/11/2018 and 03/19/2019.

Today's census: eleven children with three staff.
Violations cited during the licensing period were checked for corrections. There was one repeat violations cited. A complete renewal application will need to be submitted to the Department prior to the expiration of the license.

The Department received a renewal application for the center on 06/13/2019. A new agent was listed on the application. The violation notice was amended on 06/27/2019 as a result of background checks not being obtained for a new agent within the required time frame. See violation notice for additional details.

If you have questions regarding this inspection, please contact the licensing inspector at 804-662-9758.

Violations:
Standard #: 22VAC40-185-60-A
Description: Based on review of children's records, the center did not obtain all required information for each child's record. Evidence: 1. The record of child #2, enrolled 02/22/2019, did not contain the addresses for the two emergency contacts listed. 2. The record of child #4, enrolled 09/28/2018, did not contain the addresses for the two emergency contacts listed.

Plan of Correction: Per the program director: I will go back through and call parent to obtain missing information. At enrollment i will make sure the family advocate collects all the information and then the program director will review behind them to ensure all information in complete.

Standard #: 22VAC40-185-260-A
Description: Based on review of documentation and interview, the center did not obtain an annual fire inspection report from the appropriate fire official having jurisdiction. Evidence: The most recent fire inspection was dated 01/29/2018, exceeding the annual requirement.

Plan of Correction: Per the program director: The school had a fire inspection however the fire Marshall is not longer with the state and documentation was not provided to the school. I have left messages with the new fire Marshall who is looking into weather the fire inspection conducted will stand or if a new inspection will need to be conducted. We will obtain documentation of a fire inspection as soon as possible.

Standard #: 22VAC40-191-40-D-1-A
Description: Based on documentation review, the center did not obtain a sworn statement or affirmation and a search of the central registry before the end of 30 days after the change for one agent who is involved in the day-to-day operations of the facility.

Evidence:

1. Individual #4 was added as an board officer on the renewal application received by the Department on 06/13/2019.
2. Documentation to the Department stated Individual #4 had been appointed since November or December of 2018.
3. Documentation received to the department on 06/21/2019 stated "I am waiting for (Individual #4) Virginia CPS results.
4. A sworn statement submitted on 06/21/2019 for Individual #4 was dated 06/20/2019.

Plan of Correction: Per the administrator: Individual #4's Virginia and out of state CPS background checks have been mailed for processing. Once results are in, they will be sent to licensing and placed in her file.

Standard #: 63.2(17)-1721.1-B-2
Description: Based on review of three board officer records, the facility did not obtain a fingerprint based national background check within the required time frame. Evidence: 1. The fingerprint based national background check for board officer #1 was dated 10/12/2018. Board officers that were appointed prior to 01/21/2018 were required to obtain the fingerprint based national background check by 09/30/2018. 2. The fingerprint based national background check for board officer #2 was dated 10/09/2018. Board officers that were appointed prior to 01/21/2018 were required to obtain the fingerprint based national background check by 09/30/2018. 3. The fingerprint based national background check for board officer #3 was dated 10/11/2018. Board officers that were appointed prior to 01/21/2018 were required to obtain the fingerprint based national background check by 09/30/2018.

Plan of Correction: Per the program director: We are now aware of the background check time frames. Background checks are being obtained in a timely manner.

Standard #: 63.2(17)-1721.1-B-3
Description: Based on review of three board officer records, the center did not request an Out of State Child Abuse and Neglect Search for three board officer members by 09/30/2017.

Evidence:

1. The record of board officer #1 contained results of an out of state child abuse and neglect search dated 10/10/2018, exceeding the requirement to obtain by 09/30/2017.
2. The record of board officer #2 contained results of two out of state child abuse and neglect search, both dated 10/11/2018, exceeding the requirement to obtain by 09/30/2017.
3. The record of board officer #3 contained results of an out of state child abuse and neglect search dated 10/11/2018, exceeding the requirement to obtain by 09/30/2017.
4. Individual #4 was added as an board officer on the renewal application received by the Department on 06/13/2019.
5. Documentation to the Department stated Individual #4 had been appointed since November or December of 2018 and did not have results of an out of state CPS.
6. The sworn statement for Individual #4, dated 06/20/2019, indicated Individual #4 had lived outside of Virginia within the past five years.

Plan of Correction: Per the program director: We are now aware of the background check time frames. Background checks are being 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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