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Ms. Kathleen Creasey
5204 Clarence Street
Richmond, VA 23225
(804) 864-0934

Current Inspector: Ali Metzger (804) 662-9092

Inspection Date: Dec. 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
22VAC40-111 Transportation
22VAC40-111 Nighttime Care
22VAC40-80 THE LICENSE.
22VAC40-191 Background Checks for Child Welfare Agencies
54.1-3408 Provider must be MAT certified to administer prescription medication.
63.2 Child abuse and neglect
63.2 Licensure and Registration Procedures
63.2 Facilities and Programs

Technical Assistance:
None

Comments:
An unannounced monitoring inspection was conducted on December 12, 2018 from approximately 11:00 AM to 2:30 PM to determine the provider's compliance with licensing standards. In attendance were 13 children totaling 37 points being supervised by the provider and three assistants. Children were observed interacting with the provider/assistants, using the restroom, having lunch, and napping. Lunch today consisted of fried eggs, bacon, biscuits, green beans, fruit salad, and milk. Children's books, toys, and equipment were inspected and found to be age appropriate and in operable condition. The children's restroom was inspected with the required supplies present. The family day home had the required postings displayed. The first aid kit and emergency supplies were inspected with the required items found. The emergency preparedness plan was reviewed. There is no medication being administered at this time. Five children's records and the provider/caregiver records were inspected. The following was also inspected: emergency drill logs, parent agreements, and other pertinent information. If you have any questions regarding today's inspection, contact the licensing inspector at (804) 662-9092.

Violations:
Standard #: 22VAC40-111-920
Description: Based on observation, the provider did not ensure that the menu for the current one-week period listed any substituted food. Evidence: The licensing inspector observed that the children were served the following for lunch during the inspection: fried eggs, bacon, biscuits, green beans, fruit salad, and milk. The posted menu was observed to list a scheduled meal of chicken breast, tangerines, and milk for this day.

Plan of Correction: The provider states that the menu will be updated in the future if there are any changes made to the posted menu.

Standard #: 22VAC40-111-120-B
Description: Based on review of three caregiver records, one record did not contain the required elements. Evidence: The record for Caregiver #2 (hire date 11/8/18) did not contain documentation of two or more references prior to employment.

Plan of Correction: The provider will ensure that reference checks are made and documented prior to employment. References for Caregiver #2 will be completed and the record updated.

Standard #: 22VAC40-111-40-A
Description: Based on observation, the provider failed to ensure that the total number of children receiving care at any one time did not exceed the maximum licensed capacity of the home. Evidence: The licensing inspector observed that there were 13 children in care during the inspection. The provider's licensed capacity is 12 children at any one time.

Plan of Correction: The provider will ensure that the capacity is not exceeded in the future.

Standard #: 22VAC40-111-50-A
Description: Based on record review, observation, and interview; the family day home did not keep an accurate record of children in attendance. Evidence: 1. The licensing inspector observed there were thirteen children in care during the inspection. 2. The licensing inspector observed the attendance sheet indicated there were 11 children in care. 3. When questioned, the provider reported there were 11 children in care. The provider and the inspector compared the attendance record to a head count, at which time the provider was able to provide the names of the additional two children in care.

Plan of Correction: The provider will ensure that the attendance record is updated within the first 30 minutes of a child's arrival at the family day home.

Standard #: 22VAC40-111-60-B
Description: Based on review of five children's records, one record did not contain the required elements. Evidence: The record for Child #2 did not contain the first date of attendance. The parent had signed, but not dated, the parent information form and authorization forms.

Plan of Correction: The provider will update the child's record.

Standard #: 22VAC40-111-180-A
Description: Based on review of four provider/caregiver records, two records did not contain documentation of a current Report of Tuberculosis (TB) Screening. Evidence: The record for Provider #1 contained a TB screening which expired on 10/28/2018. The record for Caregiver #3 (hire date 7/10/06) contained a TB screening which expired on 7/11/15. Each caregiver record must contain documentation of a TB screening every two years, or more frequently as recommended by a physician.

Plan of Correction: Per the provider, the TB screenings have been completed for both parties. The provider will either locate the documentation and update the records, or will have new TB screenings completed.

Standard #: 22VAC40-111-210-A
Description: Based on review of four provider/caregiver records, the provider did not ensure that three provider/caregivers obtained a minimum of 16 clock hours of annual training. Evidence: 1. The licensing inspector observed that the record for Provider #1 contained documentation for five hours of annual training. 2. The record for Caregiver #1 (hire date 9/25/17) contained documentation for one hour of annual training. 3. The record for Caregiver #3 (hire date 7/10/06) did not contain any documentation for annual training.

Plan of Correction: The provider will ensure that annual training is completed for all providers/caregivers in the future.

Standard #: 22VAC40-111-510-A
Description: Based on observation and interview, the provider failed to ensure that a child was provided an individual crib. Evidence: 1. There was not a crib provided for child #1. Child #1 started care 9/4/18 and is six months old. According to the provider, there was no crib assigned for Child #1. 2. There were three cribs observed at the family day home. There were four children in care under the age of 12 months. There was no crib available for child available for Child #1.

Plan of Correction: Per the provider, there are usually no more than three children in care under the age of 12 months. The provider states that another crib will be provided in the home if there are four infants in care in the future.

Standard #: 22VAC40-191-60-B
Description: Based on review of three caregiver records, one record did not contain documentation of a sworn statement prior to employment. Evidence: The record for Caregiver #2 (hire date 11/8/18) contained a sworn statement signed on 11/26/18. An employee must not be employed until the home has the person's completed sworn statement.

Plan of Correction: The provider will ensure that employees submit a sworn statement prior to employment in the future.

Standard #: 63.2-1720.1-B-2
Description: Based on review of three caregiver records, three records did not contain documentation of a national fingerprint-based criminal history record check. Evidence: The records for Caregiver #1 (hire date 9/25/17), Caregiver #2 (hire date 11/8/18), and Caregiver #3 (hire date 7/10/06) did not contain documentation of a national fingerprint-based criminal history record check. As of 01/22/2018, a statement of eligibility based on a national fingerprint-based criminal history record check is required to be obtained prior to employment. For caregivers employed prior to 1/22/2018, a statement of eligibility based on a national fingerprint-based criminal history record check was required to be obtained prior to 9/30/2018.

Plan of Correction: The provider reports that Caregiver #1 has completed the fingerprint check, and the results will be located in order to update the record. The provider will ensure that the fingerprint background checks are scheduled for Caregivers 2 and 3.

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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