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Montessori School of Charlottesville
1602 Gordon Avenue
Charlottesville, VA 22903
(434) 295-0029

Current Inspector: Beth Orebaugh (540) 847-9173

Inspection Date: Nov. 30, 2016

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
63.2 General Provisions.
63.2 Licensure and Registration Procedures
63.2 Facilities and Programs..
22VAC40-191 Background Checks (22VAC40-191)

Comments:
An unannounced monitoring inspection was conducted on November 30, 2016, between the hours of approximately 10:05 a.m. and 2:00 p.m. Forty-three (43) children were enrolled and forty-one (41) children were in the care of six staff members during the on site inspection. One additional staff member was present and able to assist, as needed. Three children's records and five staff records were reviewed. Two children's medications and two children's topical ointments, as well as authorization forms and one medication log were reviewed, on this date. Safety equipment (first aid kits and flashlights), posted information (license, inspection documentation, weekly menu, emergency evacuation diagrams and classroom schedules) and available documents (emergency evacuation drill/shelter-in-place drill records, injury report forms, children's emergency contact cards and the program's Articles of Incorporation) were observed/reviewed. The morning snack included oatmeal and dried cranberries and lunches were provided by the children's parents. The facility was observed to be clean and supplied with a variety of age/stage program specific learning and play materials. Program observation was completed. Activities provided on this date included: children's work cycle and group time in the toddler classroom (washing dishes/floor, books, sequencing cards, self-serve snack and story); group time in the 3 through 6-year-old classroom (child demonstration of zipping jacket and birthday celebration); handwashing and restroom procedures; outdoor play; lunch; naptime and departure/pick-up of children. Staff/child interactions, behavior guidance and daily routines/transitions were observed. Staff members were observed to be positive, patient and supportive in their interactions with the children in their care. Refer to the Violation Notice for exceptions to compliance. Thank you for your time and assistance during this inspection. Please contact me if you have concerns regarding this inspection, the licensing standards and/or if I may be of assistance to you (540) 430-9262.

Violations:
Standard #: 22VAC40-185-160-A
Description: Based on review of five staff records and discussion with staff on November 30, 2016, the program failed to obtain documentation of negative tuberculosis (TB) screenings for two staff members within 21 days after employment. Evidence: Review of staff #3 and staff #5's records, on this date, determined that documentation of TB screenings was not included in the records. Staff #3's employment date was 8/24/2016 and staff #5's employment date was 5/26/2016.

Plan of Correction: Administration will obtain TB results and be more careful about timely completion of staff files.

Standard #: 22VAC40-185-70-A
Description: Based on review of five staff records and discussion with staff on November 30, 2016, the program failed to ensure references, orientation training and/or education/certification were included in four staff records. Evidence: 1. Review of staff #2's record, on this date, revealed that verification of program leader qualifications was not included in the record. 2. Review of staff #3, #4 and #5's records, on this date, revealed that documentation of two or more reference checks was not included in the staff records. 3. Review of staff #3 and #5's records, on this date, revealed that documentation of orientation training was not included in the staff records.

Plan of Correction: Will get documentation of qualifications and references asap. Orientation documentation will be put into file.

Standard #: 22VAC40-185-240-C
Description: Based on review of five staff records and discussion with staff #2 on November 30, 2016, the program failed to ensure documentation of 16 hours of annual training for 2015/2016 was completed/documented for two staff members. Evidence: 1. Review of staff #2's record, on this date, determined that there was no documentation of annual training hours for 2015/2016. 2. Staff #2 stated that the required 16 training hours had been completed but had not been documented. 3. Review of staff #1's record, on this date, determined that only 10 of the required 16 annual training hours had been completed for 2015/2016. 4. Staff #1 stated that only 10 of the required 16 training hours had been completed for 2015/2016.

Plan of Correction: #2 documentation in place 12/02/12. #1 will document additional observations and staff development for 2015-16 and complete file.

Standard #: 22VAC40-185-320-B
Description: Based on observation, measurements taken of the water temperature and discussion with staff #1 on November 30, 2016, the program failed to ensure the water temperature did not exceed 120 degrees F. Evidence: 1. Measurements of the water temperature, taken at one upstairs bathroom sink and the kitchen sink, revealed that the water temperature measured approximately 123.3 degrees F at the bathroom sink and 125 degrees F at the kitchen sink. 2. Staff #1 verified the water temperature at the kitchen sink.

Plan of Correction: Water heater turned down on 12/2.

Standard #: 22VAC40-185-500-B
Description: Based on observation and discussion with staff on November 30, 2016, the program failed to ensure that a changing table or countertop, designated for diaper changing, was available for children under the age of three years. Evidence: On this date, staff identified two children who were in diapers and not yet potty trained. Both children were under the age of three years.

Plan of Correction: Work in progress on variance request. Will be mailed.

Standard #: 22VAC40-185-520-C
Description: Based on observation/review of two children's topical ointments and discussion with staff on November 30, 2016, the program failed to obtain written parent authorization, noting any adverse reactions, for one child's topical ointments. Evidence: 1. Review of child G's topical ointments (Desitin and Cortizone), on this date, determined that written parent authorization to apply the products was not on file. 2. Staff #2 confirmed the lack of parent authorization.

Plan of Correction: School policy dictates that no ointments be here without written authorization. Form will be found or replaced.

Standard #: 22VAC40-191-40-D-1-B
Description: Based on review of five staff records on November 30, 2016, the facility failed to obtain a central registry check for one staff member before 30 days of employment at the facility ended. Evidence: 1. Review of staff #3's record, on this date, established that a central registry check was not included in the staff member's file. 2. Staff #3's date of employment was 8/24/2016.

Plan of Correction: Staff had tried to get copy from previous school. Will send new request.

Standard #: 22VAC40-191-40-D-1-C
Description: Based on review of five staff records on November 30, 2016, the program failed to update criminal history record checks (CRC) for two staff members before 3 years since the date of the most recent CRC report. Evidence: 1. An updated CRC was not on file for staff #1 (date of most recent CRC report was 6/06/2013). 2. An updated CRC was not on file for staff #2 (date of most recent CRC report was 9/18/2013).

Plan of Correction: Forms will be returned to us and sent to DSS. Administration will be more proactive to have staff files updated on time.

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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