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Little Tin Soldiers Educational Center
199 East Mercury Boulevard
Hampton, VA 23669
(757) 727-0780

Current Inspector: Michele Patchett (757) 439-6816

Inspection Date: Dec. 13, 2017

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.
22VAC40-191 Background Checks (22VAC40-191)

Comments:
An unannounced renewal inspection was conducted on December 13, 2017. There were 18 children present upon arrival to the center with three staff members. Additional staff arrived throughout the course of the inspection who were on site for administrative and support purposes. There is a total enrollment of 55 children. The children were observed during circle time, storytime and playing in centers. The infants were observed having tummy time, crawling, napping and feeding in the Infant room. Five children's records were reviewed. Five staff records were reviewed. Medications are currently not being administered. The exit interview was conducted with the Program Director.

Violations:
Standard #: 22VAC40-185-140-A
Description: Based on record review, in three of five children's records reviewed, the licensee did not ensure that each child shall have a physical examination by or under the direction of a physician: Before the child's attendance or within one month after attendance. Evidence: During the inspection conducted on December 13, 2017, there was no documentation of physical examinations in the records for the following children: Child #1-start date 7/31/17 Child #2-start date 9/18/17 Child #4-start date 9/7/17

Plan of Correction: Program Director will contact the parents today and ask for updated documentation and physical paperwork.

Standard #: 22VAC40-185-150-B
Description: Based on record review, in three of five children's records reviewed, the licensee did not ensure that each child's medical report shall be signed by a physician, his designee, or an official of a local health department. Evidence: During the inspection conducted on December 13, 2017, the following medical reports had not been signed by a physician, his designee, or an official of a local health department for each child: Child #2 and Child #4-no signature on the immunizations Child #3-no signature on the physical or immunizations

Plan of Correction: Program Director will contact the parents today and ask for updated and signed documentation.

Standard #: 22VAC40-185-160-A
Description: Based on record review, the licensee did not ensure that each staff member shall submit documentation of a negative tuberculosis (PPD) screening no later than 21 days after employment. Evidence: During the inspection conducted on December 13, 2017, there was no documentation of a negative PPD screening submitted for Staff #1 (date of hire 10/02/17) and Staff #3 (date of hire 9/19/17).

Plan of Correction: Program Director will make sure that staff provide proper documentation of TB test results.

Standard #: 22VAC40-185-160-C
Description: Based on record review, the licensee did not ensure that staff resubmit TB test results every two years. Evidence: During the inspection conducted on December 13, 2017, the following TB screenings were more than two years old and expired for staff members: Staff #4: 9/8/15 Staff #5: 9/10/15

Plan of Correction: Program Director will make sure staff bring in proper documentation of the results of the TB screenings.

Standard #: 22VAC40-185-60-A
Description: Based on record review, in five of five children's records reviewed, the licensee did not ensure that the center maintained a separate record for each child enrolled with all required information. Evidence: During the inspection conducted on December 13, 2017, the following information was not documented in each child's record: Child #1-no established record Child #2-names of any additional programs or schools that the child is concurrently attending and the grade or class level Child #3-no established record Child #5-work phone number for one parent

Plan of Correction: Program Director will update each child's record with the proper documentation that's missing or incomplete.

Standard #: 22VAC40-185-70-A
Description: Based on record review, in three of five staff records reviewed, the licensee did not ensure that each staff record was documented with all required information. Evidence: During the inspection conducted on December 13, 2017, in the records for Staff #1, Staff #2 and Staff #3, there was no documentation of job titles and documentation of two or more references as to character and reputation as well as competency were checked before employment

Plan of Correction: Program Director will update the staff's folders with all missing documentation.

Standard #: 22VAC40-185-240-D-5
Description: Based on observation and review of staff records, the licensee did not ensure that there shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation (DHO) of children. Evidence: During the inspection conducted on December 13, 2017, upon arrival to the facility, there were three staff members present and none of the staff present had documentation of current DHO training.

Plan of Correction: Program Director has current DHO training and was present throughout the rest of the inspection.

Standard #: 22VAC40-185-260-A
Description: Based on observation and inspection of the facility, the center did not provide to the licensing representative an annual fire inspection report. Evidence: During the inspection conducted on December 13, 2017, the fire inspection report for the facility expired and was dated 8/10/16.

Plan of Correction: Fire Marshall's office has been contacted and inspection has been scheduled for Friday morning.

Standard #: 22VAC40-185-340-D
Description: Based on observation and review of staff records, the licensee did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present. Evidence: During the inspection conducted on December 13, 2017, the licensing inspector observed Staff #1 working alone in the Toddler classroom and Staff #2 working alone in the Infant classroom, a review of staff records determined that neither staff member met the qualifications of a program leader or program director.

Plan of Correction: Program Director will make sure that both teachers get the proper qualifications to become lead teacher qualified.

Standard #: 22VAC40-185-440-J
Description: Based on observation and inspection of the facility, the licensee did not ensure that there shall be at least thirty inches of space between service sides of occupied cribs and other furniture where that space is the walkway for staff to gain access to any occupied crib. Evidence: During the inspection conducted on December 13, 2017, the licensing inspector observed four occupied cribs in the Infant room with approximately 12 inches of space between the service sides of the cribs used to access the infants.

Plan of Correction: Staff corrected while the inspector was present.

Standard #: 22VAC40-185-550-A
Description: Based on staff interview and inspection of the facility, the licensee did not ensure that the center shall have an emergency preparedness plan that addresses staff responsibility and facility readiness with respect to emergency evacuation and shelter-in-place. Evidence: During the inspection conducted on December 13, 2017, the center did not have documentation of an emergency preparedness plan.

Plan of Correction: Program Director will make sure that the plan is easily accessible in the Director's Book.

Standard #: 22VAC40-191-40-D-1-C
Description: Based on record review, in two of five staff records reviewed, the licensee did not ensure that any applicant, licensee, agent, or employee has repeat background checks before three or five years since the dates of the most recent criminal history record check report and central registry findings. Evidence: During the inspection conducted on December 13, 2017, the following background checks had not been updated for staff and agents of the corporation: 1. The most recent criminal history record checks for the following staff and agents were more than three years old: Staff #4: 6/5/14 Staff #5: 12/6/14 Staff #6: 2/21/14 Staff #7: 11/20/13 2. The most recent central registry findings for Staff #7 was dated 9/16/11 3. There was no copy of a sworn statement or affirmation for Staff #7.

Plan of Correction: Agent completed a new sworn statement while inspector was present. Program Director will have staff fill out new documents which will be sent out immediately.

Standard #: 22VAC40-191-60-B
Description: Based on record review, in three of five staff records reviewed, the licensee did not ensure that an employee of a licensed child welfare agency must not be employed until the agency has the person's completed sworn statement or affirmation. Evidence: During the inspection conducted on December 13, 2017, the center had not required that the following staff hired after July 1, 2017, complete the most recent version of the sworn statement or affirmation: Staff #1 (date of hire 10/02/17); Staff #2 (date of hire 10/23/17); and Staff #3 (date of hire 9/19/17).

Plan of Correction: All staff will be updated with the new sworn statements.

Standard #: 22VAC40-191-60-C-2
Description: Based on record review and inspection of the facility, the licensee did not ensure that the center would deny continued employment to a staff member when the center did not have a central registry finding within 30 days of employment. Evidence: During the inspection conducted on December 13, 2017, there were no central registry findings by the end of the 30th day of employment for the following staff members: Staff #1 (date of hire 10/02/17); Staff #2 (date of hire 10/23/17) and Staff #3 (date of hire 9/19/17).

Plan of Correction: Program Director will make the necessary phone calls to do a follow up to check the status of the paperwork.

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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