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Birktawet Hager
43057 Battery Point Place
Leesburg, VA 20176
(703) 587-2990

Current Inspector: Sarah Marbert (703) 479-4678

Inspection Date: Sept. 8, 2017

Complaint Related: No

Areas Reviewed:
22VAC40-111 Administration
22VAC40-111 Personnel
22VAC40-111 Household Members
22VAC40-111 Physical Health of Caregivers and Household Members
22VAC40-111 Caregiver Training
22VAC40-111 Physical Environment and Equipment
22VAC40-111 Care of Children
22VAC40-111 Preventing the Spread of Disease
22VAC40-111 Emergencies
22VAC40-111 Nutrition
22VAC40-111 Transportation
63.2 Licensure and Registration Procedures
63.2 Facilities and Programs..
63.2 Liability Insurance Disclosure
22VAC40-191 Background Checks for Child Welfare Agencies
54.1-3408 Provider must be MAT certified to administer prescription medication.

Technical Assistance:
Discussed the following with the Provider: meal preparations involving blending fruits and vegetables into the food served, changes in legislation to the background checks.

Comments:
An unannounced renewal inspection was initiated today at 10:30am. The physical plant, 5 caregiver/household member files, 5 children's files, caregiver training, child nutrition, children's activities, emergency procedures, drills and supplies were inspected today. There were 12 children, totaling 32 points, under the supervision of 3 caregivers. During the inspection, children were observed eating lunch, enjoying free play, cleaning up for and resting at nap time. The interactions between the children and caregivers were seen to be positive and constructive in nature. Today, the children were served pasta with meat, tomato sauce, broccoli, red and green peppers and milk. The Provider is currently certified in MAT (medication administration training). However, there are no children with any medication needs during program hours at this time. Should you have any questions, please contact me at mary.wizbicki@dss.virginia.gov.

Violations:
Standard #: 22VAC40-111-920
Description: Based on observations and interview, there was no posted menu. Evidence 1.The Provider stated that she has this on an excel spreadsheet, but it has not been posted.

Plan of Correction: The Provider will post weekly menus.

Standard #: 22VAC40-111-120-B
Description: Based on file review, 1 out of 3 assistant records does not have all required information. Evidence 1. Caregiver #5 does not have the following information on file: date of employment, name address and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment.

Plan of Correction: The Provider will get this information.

Standard #: 22VAC40-111-60-A
Description: Based on file review, 3 out of 5 children's records have not been updated annually. Evidence 1. Child #1's record was last updated on 9/18/15. 2. Child #2's record was last updated on 8/6/16. 3. Child #5's record was last updated on 7/22/16.

Plan of Correction: The Provider will have the parents review, sign and date their files.

Standard #: 22VAC40-111-90-C
Description: Based on file review, 1 out of 5 children's records does not have documentation of additional immunizations once every six months for children under the age of two years. Evidence 1. Child #4 is 28 months old. The most recent immunization record on file was last updated when the child was 15 months old.

Plan of Correction: The Provider will ask the parents to bring the most recent immunization record into the FDH.

Standard #: 22VAC40-111-140-B-3
Description: Based on file review, the Provider does not have documentation of being certified in CPR. Evidence 1. The most recent CPR certification card for the Provider expired on 8/15/17.

Plan of Correction: This certification will be renewed.

Standard #: 22VAC40-111-140-B-4
Description: Based on file review, the Provider does not have documentation of being certified in First Aid. Evidence 1. The most recent First Aid certification card for the Provider expired on 8/15/17.

Plan of Correction: This certification will be renewed.

Standard #: 22VAC40-111-150-D-1
Description: Based on file review, 1 of the assistants does not have documentation of being certified in CPR. Evidence 1. The most recent CPR certification card for caregiver #2 expired on 6/1/17.

Plan of Correction: This certification will be renewed.

Standard #: 22VAC40-111-150-D-2
Description: Based on file review, 1 of the assistants does not have documentation of being certified in First Aid. Evidence 1. The most recent First Aid certification card for caregiver #2 expired on 6/1/17.

Plan of Correction: This certification will be renewed.

Standard #: 22VAC40-111-180-A
Description: Based on file review, 1 out of 5 caregiver/household members does not have documentation of a TB test/screening having been completed within the past two years. Evidence 1. Caregiver #4's most recent TB test was completed on 6/16/15.

Plan of Correction: This will be completed again.

Standard #: 22VAC40-111-200-A
Description: Based on file review, 1 of the assistants does not have documentation of having received orientation training. Evidence 1. Caregiver #5 does not have an orientation form on file to verify having received this training.

Plan of Correction: This form will be completed.

Standard #: 22VAC40-191-40-D-1-c
Description: Based on file review, 3 out of 5 caregiver/household members do not have a search of the central registry (SCR) completed within the past three years. Evidence 1. Caregivers #1, #2 and #3 have SCRs which were last completed on 6/21/14.

Plan of Correction: These checks will be completed again.

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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