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(Under the authority of Executive Order 51, the Commissioner of Department of Social Services is waiving regulation 22VAC40-665-40.N which references the period of time for a redetermination of eligibility for the subsidy program. )

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Blessed Sacrament School - Extended Day Program
1417 West Braddock Road
Alexandria, VA 22302
(703) 998-4170 (26)

Current Inspector: Anansa Archer-Hicks (703) 268-3295

Inspection Date: May 25, 2016

Complaint Related: No

Areas Reviewed:
22VAC40-191 Background Checks (22VAC40-191)

Technical Assistance:
Consultation was given on the VA DSS web site and the change to the Criminal Record Checks that will go into effect July 2017.

An unannounced renewal study was conducted during the after preschool and school-age care. Both groups were in ratio with direct care staff. Snack served today was carrots and dressing, grape juice and rice cakes. Children were observed transitioning to hand washing, snack, homework, reading and looking over the school yearbook as well as free play. Records for several staff, children, medication and storage, emergency preparation as well as administration requirements were reviewed. Areas of non-compliance are identified in this report. Please sign and date the report and return it to me within 10 calendar days from date of receipt. If you have any questions regarding the inspection, please feel free to contact me. Thank you Ann Dramstad Licensing Inspector 703-314-0860

Standard #: 22VAC40-185-160-A
Description: Based on center management records and statement, a TB screening for two staff was not conducted within 21 days of hire. Evidence: Staff #1 and Staff were hired August 2015 and do not have TB documentation in their personnel files that a screening or test has been completed.

Plan of Correction: Update files with necessary documentation.

Standard #: 22VAC40-185-260-C
Description: Based on documentation, asbestos inspections are required to be conducted by a licensed professional every three years and has not been done since the previous inspection. Evidence: The last documented inspection done by a asbestos management company was conducted 8/2011 and has not been repeated.

Plan of Correction: Advise our facilities manager to investigate and get back on schedule.

Standard #: 22VAC40-185-510-C
Description: Based on observation, an outdated medication is on-site. Evidence: A over the counter medication for child #1 expired 4/2016.

Plan of Correction: Return medication and request current dated medication.

Standard #: 22VAC40-185-510-E
Description: Based on observation, an emergency medication is not labeled. Evidence: Child #1's emergency medication is loose in a zip lock bag and is not in the original prescription box with the label containing the child's name, dosage amount and times to be given.

Plan of Correction: Acquire properly labeled box.

Standard #: 22VAC40-185-550-D
Description: Based on evacuation log, monthly fire evacuations were not conducted. Evidence: No evacuation drills were conducted the months of February and March 2016.

Plan of Correction: Be sure to conduct monthly drills.

Standard #: 22VAC40-185-550-M
Description: Based on record review, 2 of 15 injury forms are incomplete. Evidence: 2 forms are missing "Future action to prevent reoccurrence"

Plan of Correction: Instruct staff to ALWAYS include section on "future action"

Standard #: 22VAC40-191-40-D-1-B
Description: Based on record review, two staff do not have completed Central Registry Searches (CPS) records within 30 days of their hire. Evidence: Staff #1 was employed 8/28/2015 and does not have a completed CPS search. Staff #2 was employed 8/12/2015 and does not have a completed CPS search.

Plan of Correction: Complete and submit CPS

Standard #: 22VAC40-191-40-D-3-D
Description: Based on record review, a staff member did not have current background searches within three years of completing the most recent documentation on record. Evidence: Staff #3 has expired background searches 1. SDS expired 2/4/2016 2. CPS expired 4/9/2016 3. CRC expired 3/21/2016

Plan of Correction: Update all searches.

Standard #: 22VAC40-191-60-C-2
Description: Based on observation, two staff have not been denied employment after 30 days without a completed CPS finding. Evidence: Staff #1 and Staff #2 are continued to be employed past the 30 days of their employment date (October 1, 2015)

Plan of Correction: Inform staff of need to await paperwork before returning to work.

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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