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Lucia Martinez
5646 Kathryn Street
Alexandria, VA 22303
(703) 960-6438

Current Inspector: Jessica Willis (571) 352-1453

Inspection Date: Nov. 15, 2019

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
22VAC40-80 THE LICENSE.
22VAC40-191 Background Checks for Child Welfare Agencies

Technical Assistance:
Discussed with provider required information for children's and caregiver records and location of model forms available on the dss website. Discussed with provider that a renewal application must be received prior to license expiry date (12/06/19) in order to renew the license for the family day home.

Comments:
An unannounced renewal inspection was conducted today between the hours of 10am through 2:30pm with the provider on site. There were 10 children (24 points) with the provider and one caregiver present. A sample of 4 children's files and 3 caregiver/household member's files were reviewed. The children were engaged in the following: identifying colors, letters and shapes, playing with toys, lunchtime, and naptime. The physical space, emergency supplies, evacuation drills, attendance records, and the Emergency Preparedness Plan were reviewed. Areas of non-compliance are identified in the violation notice. A Subsidy Health and Safety Inspection (SHSI) was also conducted today. Please contact me if you have any questions at jessica.willis@dss.virginia.gov or 571-352-1453.

Violations:
Standard #: 22VAC40-111-780-B
Description: Based on record review, the provider did not annually review with the parent the emergency contact information required in 22 VAC 40-111-60 B 2 to ensure the information is correct, and obtain the parent's signed acknowledgment of the review for 2 of 4 children.

Evidence:
1. Child #1 began attending the family day home on 6/13/16. There is no documented review of the emergency contact information for Child #1 in the child's record.
2. Child # 3 began attending the family day home in April 2017. There is no documented review of the emergency contact information for Child #3 in the child's record.

Plan of Correction: I will ask the parents to review the information.

Standard #: 22VAC40-111-800-A
Description: Based on record review and caregiver interview, the family day home did not have a written emergency preparedness and response plan.

Evidence:
An emergency preparedness and response plan was not available for review at the time of the inspection. Caregiver stated an emergency preparedness and response plan was currently on the computer but was unable to provide it during the inspection.

Plan of Correction: I will ask my daughter to print it tonight.

Standard #: 22VAC40-111-920
Description: Based on observation and caregiver interview, the family day home did not provide a current menu.

Evidence:
Caregiver stated lunch is provided in the family day home. Caregiver stated a current menu had not been created to be posted or provided to parents.

Plan of Correction: I will print the menu from the computer.

Standard #: 22VAC40-111-100-A
Description: Based on record review, the provider did not obtain documentation of of a physical examination by or under the direction of a physician within 30 days after the first day of attendance for one child.

Evidence:
Child #3 began attending the family day home in April 2017. There is no documentation of a physical examination for Child #3 available for review.

Plan of Correction: I will ask the parents to bring me the papers for the physical.

Standard #: 22VAC40-111-120-B
Description: Based on record review, one caregicer record did not contain all required information.

Evidence:
The record for Caregiver #1 did not contain the following information:
-date of employment
-verification of age
- Name address and telephone number of a person to be notified in an emergency
-documentation of 2 of 2 references

Plan of Correction: I will fill out the forms and put the information in the file. I will make a copy of their id.

Standard #: 22VAC40-111-60-A
Description: Based on record review and caregiver interview, the provider did not maintain a record at the family day home for one enrolled child.

Evidence:
Provider stated Child #4 began attending the family day home on 10/28/19. Provider stated she has requested information from the parents, but there is no record for Child #4.

Plan of Correction: I have asked for the information from the parents and they have not returned it to me. I will talk with the parents again.

Standard #: 22VAC40-111-60-B
Description: Based on record review, 4 of 4 children's records did not contain all required information.

Evidence:
1. The record for Child #1 and Child #3 did not contain an address for 2 of 2 designated persons to contact in case of an emergency if the parent cannot be reached. The record for Child #2 did not contain an address for 1 of 2 designated persons to contact in case of an emergency if the parent cannot be reached,
2.The record for Child #1 did not contain the address and telephone number of the father's place of employment.
3. The record for Child #2 did not contain the policy number of the child's medical insurance.
4. The record for Child #3 did not contain names of persons other than the custodial parents who are authorized to pick up the child.
5. The record for Child #3 did not contain the child's first date of attendance.

Plan of Correction: I will ask the parents for the information.

Standard #: 22VAC40-111-70-A
Description: Based on record review, 4 of 4 children's parent's were not provided in writing all required information before the child's first date of attendance.

Evidence:
1. The records for Child #2 and #3 did not contain notification of whether or not there is liability insurance.
2. The records for Child #2, #3, and #5 did not contain documentation of policies for the administration of medications.
3. The records for Child #1, #2, and #3 did not contain provisions of the family day home's emergency preparedness and response plan.
The records for Child #1, #2, #3, and #5 did not contain documentation of notification of information included in 22VAC40-111-(2)-70-A 1-3, 22VAC40-111-(2)-70-A 6-15, and 22VAC40-111-(2)-70-A 17-19 which covers the family day home's operating information.

Plan of Correction: I will print the dss model forms and give to all parents and have them sign.

Standard #: 22VAC40-111-80-C
Description: Based on record review, 3 of 4 children's records reviewed did not contain complete documentation of proof of identification for each child in care.

Evidence:
1. The record for Child #1 was missing the method of verification of the child's age and identity.
2. The records for Child #1, #2, and #5 were missing documentation of date and person verifying original documentation.

Plan of Correction: The documents for Child #2 and #5 were corrected during inspection. I will write down the information for the other child.

Standard #: 22VAC40-111-90-A
Description: Based on record review and caregiver interview, the provider did not obtain documentation that 2 children had been adequately immunized before the children began attending the family day home.

Evidence:
1. Provider stated Child #3 began attending the family day home in April 2017. There is no documentation of immunizations available for review for Child #3.
2. Provider stated Child #4 began attending the family day home on 10/28/19. There is no documentation of immunizations available for review of Child #4.

Plan of Correction: I will ask the parents for the immunizations.

Standard #: 22VAC40-111-90-C
Description: Based on record review, the family day home did not obtain documentation of additional immunizations once every six months for one child under the age of two years.

Evidence:
Child #5 is under the age of two years. The most recent immunizations for Child #5 available for review were dated 2/27/18.

Plan of Correction: I will ask the parents for updated immunizations.

Standard #: 22VAC40-111-170-A
Description: Based on record review, an adult household member does not have documentation that a tuberculosis screening or test has been completed to document the absence of tuberculosis in a communicable form.

Evidence:
1. Adult household member #1 does not have documentation of a tuberculosis screening or test has been completed.

Plan of Correction: I will send you the documentation tonight and put it in the file.

Standard #: 22VAC40-111-180-A
Description: Based on record review, the provider did not obtain documentation of subsequent tuberculosis screenings one caregiver every two years.

Evidence:
The most recent tuberculosis screening for Caregiver #1 available for review was dated 7/17/17.

Plan of Correction: I will have them get the tb test next week.

Standard #: 22VAC40-111-230-A
Description: Based on record review, the provider did not maintain written documentation of one caregiver's orientation training.

Evidence:
Caregiver stated Caregiver #1 began employment in December 2018. There is no documentation of orientation training for Caregiver #1 available for review.

Plan of Correction: I will fill out the forms and put the information in the file.

Standard #: 22VAC40-191-40-D-4-a
Description: Based on record review, the provider did not obtain a completed sworn disclosure of affirmation from a household member within 30 days of a person in the home becoming 18 years old.

Evidence:
Household member (HHM) #1 turned 18 on 2/27/2019. The sworn disclosure for HHM #1 does not include a signature or date of completion.

Plan of Correction: I will have them sign the form.

Standard #: 22VAC40-191-60-B
Description: Based on record review, the family day home did not obtain a completed sworn statement or affirmation for one caregiver prior to employment at the family day home.

Evidence:
Caregiver stated Caregiver #1 began employment in December 2018. There is no documentation of a sworn statement or affirmation available for review.

Plan of Correction: I will have them fill out the form.

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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