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Chesterbrook Academy #822
4750 Rippling Pond Drive
Fairfax, VA 22033
(703) 818-9002

Current Inspector: Nancy Radcliffe

Inspection Date: Aug. 8, 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.
22VAC40-191 Background Checks (22VAC40-191)
63.2 Child Abuse & Neglect
63.2(17) License & Registration Procedures
63.2 Facilities & Programs.

Technical Assistance:
Technical assistance was provided regarding reviewing the standards and better systems to prevent outdated, expired items.

Comments:
An unannounced renewal inspection was conducted today from 8:00am-11:30am. There were 62 children supervised by 9 direct care staff. The physical plant, programming, 10 staff records, 10 children?s records, 9 medications, evacuation drills, injury reports, emergency supplies, and policies were inspected. Children were observed participating in group play, reading books, building and during circle time. Diapering and hand-washing procedures were also observed. There was an abundance of books, toys, and materials, which were found to be developmentally appropriate for the children in care at the time of inspection. There was an adequate number of staff with current certification in MAT, CPR and First Aid, as well as DHO training. Staff-to-child ratios were in compliance. Areas of non-compliance are identified in the Violation Notice. Thank you for your cooperation during this inspection. If you have any questions regarding this inspection, please contact nancy.radcliffe@dss.virginia.gov or call 703-268-3728.

Violations:
Standard #: 22VAC40-185-160-A
Description: Based on review of 10 staff records, 1 does not have documentation of submitting a negative tuberculosis (TB) screening within 21 days of employment. Evidence: Staff #2, start date 5/6/19, does not have documentation of submitting a negative TB screening within 21 days of employment.

Plan of Correction: We will make sure all staff have current TB screenings.

Standard #: 22VAC40-185-160-C
Description: Based of review of 10 staff records, 2 do not have an updated tuberculosis (TB) screening every 2 years. Evidence: Staff #1 (hire date 7/17) and staff #3 (hire date 8/15) do not have documentation of an updated TB screening.

Plan of Correction: Staff will get an updated TB screening.

Standard #: 22VAC40-185-40-J
Description: Based on review of emergency records, there is no documentation of an Injury Prevention Plan. Evidence: The is no Injury Prevention Plan to review.

Plan of Correction: I am currently working on putting a Injury Prevention Plan together.

Standard #: 22VAC40-185-270-A
Description: Based on observation, not all areas of the center are being maintained in a clean, safe condition. Evidence: There is peeling, chipped paint in the PreK 2 classroom along the side and back walls.

Plan of Correction: We have a work order already submitted, they should be here by next year.

Standard #: 22VAC40-185-290-3
Description: Based on observation, not all electrical outlets are inaccessible to children with protective covers. Evidence: Outlets in the Pre K 1 and 2 rooms have electrical outlets uncovered making them accessible to children.

Plan of Correction: We will make sure they are covered and speak with the staff about doing a morning visual check to make sure all outlets have covers.

Standard #: 22VAC40-185-420-E-3
Description: Based on review of 10 children's records, 2 are incomplete. Evidence: Children #4 & 5 do not have documentation of annual parental review of emergency contacts. Last review was 10/17 & 6/16 respectively.

Plan of Correction: We are in the process of reviewing gall the files and getting updates.

Standard #: 22VAC40-185-440-B
Description: Based on observation, cots are not being identified for use by a specific child. Evidence: Cots in the classroom are not labeled for use by an individual child.

Plan of Correction: We will label the cots and use a cot chart.

Standard #: 22VAC40-185-500-A
Description: Based on observation, hands are not being washed after diaper changes. Evidence: In the Toddler classroom: A child's hands were not washed after a diaper change. A staff removed their gloves, but did not wash their hands after a diaper change.

Plan of Correction: We will review diapering procedures with all staff.

Standard #: 22VAC40-185-500-B
Description: Based on observation, the diapering surface is not being cleaned and sanitized according to the standards. Evidence: The diapering surface is not being sprayed with a solution of soap & water, wiped dry, sprayed with a solution of bleach & water and allowed to air dry. The center is changing the paper barrier between changes, the standards state a paper barrier can be used and must be changed between diaper changes if it becomes soiled or dirty.

Plan of Correction: We handed out diapering procedures this week to all staff, we will review the procedures again with all staff.

Standard #: 22VAC40-185-510-A
Description: Based on review of 9 medications, 1 does not have written permission from a parent to administer the medication. Evidence: Child #1 has a medication authorization on site that does not have a parental signature giving authorization to administer medication.

Plan of Correction: I will have the parent sign the medical authorization form.

Standard #: 22VAC40-185-510-C
Description: Based on review of 9 medications, 1 does not have authorization signature from a physician to administer the medication. Evidence: Child # 2 has a medication authorization without a physicians signature.

Plan of Correction: I will have the parent obtain the physicians signature.

Standard #: 22VAC40-185-510-N
Description: Based on review of 9 medication authorizations, 1 is outdated and medication has not been disposed of. Evidence: Child #2 has a medication authorization that expired on 5/10/2019. Medication has not been disposed of or returned to parent.

Plan of Correction: I will give the medication or get a new authorization.

Standard #: 22VAC40-185-520-A
Description: Based on observation, not all over the counter skin products are labeled with child's name. Evidence: Topical skin cream located in the Beginners classroom was not labeled with child's name.

Plan of Correction: Corrected during the inspection, we will make sure the parents labeled all topical creams with child's name when they bring them in.

Standard #: 22VAC40-185-550-M
Description: Based on review of written records of children's injuries, records are incomplete. Evidence: Incident/Accident reports are incomplete, items missing include: time and date parents were notified, children's last names, 2 signatures and ways to prevent injury from happening again.

Plan of Correction: We went over the reports at a recent staff meeting, management will review the report before we sign them.

Standard #: 63.2(17)-1720.1-B-3
Description: Based on review of 10 staff records, 1 does not have documentation of an out of state background check, from a state that have lived in within the past five years. Staff #4 does not have an out of state background check for two states she has lived in within the past five years.

Plan of Correction: I will follow up and find out where the background checks are and send them to you within 10 days.

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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