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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: Feb. 12, 2018

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 Medication Administration
22VAC40-111 Emergencies
22VAC40-111 Nutrition
22VAC40-80 THE LICENSE.
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.

Comments:
An unannounced monitoring inspection was initiated today at 2:00pm. The physical plant, 4 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 10 children, totaling 25 points, under the supervision of 3 caregivers. During the inspection, children were observed taking naps, cleaning up from naptime, and enjoying free play. The interactions between the children and caregivers were seen to be positive and constructive in nature. Today, the children were served turkey on toast, cucumber, carrots 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, the posted menu did not reflect what was served to the children today. Evidence 1.The menu had "salmon or chicken salad in a pita", but the children were served turkey on toast for lunch today.

Plan of Correction: The Provider will document on the menu when changes are made.

Standard #: 22VAC40-111-60-B
Description: Based on file review, 3 out of 5 children's records do not have all required information. Evidence 1. Child #2 does not have the name and policy number of the child's medical insurance 2. Children #4 and #5 do not have the policy numbers for their medical insurance.

Plan of Correction: The Provider will ask the parents for this.

Standard #: 22VAC40-111-90-C
Description: Based on file review, 2 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 #1 is 25 months old. The most recent immunization record on file was last updated when the child was 15 months old. 2. Child #5 is 17 months old. The most recent immunization record on file was last updated when the child was 4 months old.

Plan of Correction: The Provider will ask the parents for this.

Standard #: 22VAC40-111-140-B-3
Description: Based on file review, the Provider does not have CPR certification from an acceptable organization. Evidence 1. The CPR certification card for the Provider was issued by American Health Care Academy on 11/30/17

Plan of Correction: This will be completed by an acceptable organization.

Standard #: 22VAC40-111-140-B-4
Description: Based on file review, the Provider does not have First Aid certification from an acceptable organization. Evidence 1. The First Aid certification card for the Provider was issued by American Health Care Academy on 11/30/17

Plan of Correction: This will be completed by an acceptable organization.

Standard #: 22VAC40-111-200-A
Description: Based on file review, 2 of the assistants do not have documentation of having received orientation training by the end of their first week of assuming job responsibilities. Evidence 1. Caregiver #2 and #3 do not have an orientation form on file to verify having received this training.

Plan of Correction: The Provider will complete these forms.

Standard #: 22VAC40-191-40-D-1-c
Description: Based on file review, 2 out of 4 caregiver/household members do not have a search of the central registry (SCR) completed within the past three years. Evidence 1. Caregivers #1 and #4 have SCRs which were last completed on 6/21/14. The Provider completed the criminal history record check again instead of completing the SCR.

Plan of Correction: The Provider will complete the SCR.

Standard #: 22VAC40-80-120-E-2
Description: The findings of the most recent inspection of the facility were not posted. Evidence 1. The Provider posted the Inspection Summary from the inspection completed on 9/8/17. However, the findings on the Violation Notice were not posted.

Plan of Correction: Today's Violation Notice will be posted.

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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