VIRGINIA DEPARTMENT OF SOCIAL SERVICES

St. Luke's United Methodist Church
300 Ella Taylor Road
Yorktown, VA 23692
(757) 898-3017

VDSS Contact: Christine Mahan (757) 404-0568

Inspection Date: April 17, 2024

Complaint Related: No

Areas Reviewed:

22.1 Religious Exempt; Background Checks Code; Carbon Monoxide 32.1 Report by person other than physician 54.1 Must be MAT Certified 63.2 Child abuse and neglect 8VAC20-770 Background Checks

Comments:

A code compliance inspection was initiated on and concluded on April 17, 2024. There were 26 children present, ranging in ages from 3 to 5 with 6 staff supervising.. Additional administrative staff were present. A total of 12 staff records were reviewed. The inspection started at 11:20AM and concluded at 1:00PM. Information gathered during the inspection determined non-compliance(s) with applicable code sections and violations were documented on the violation notice issued to the program. Please contact Christine Mahan, Licensing Inspector with any questions (757)404-0568. Inspection summary was amended on May 15, 2024 due to a technical error.

Violations:

Standard #:	22.1-289.031-A-4
Description:	Repeat Based on record review and interview with staff, the center did not ensure each person in a supervisory position must be certified by a practicing physician or physician assistant to be free from any disability that would prevent them from caring for children under their supervision. Evidence: The record for Staff #12 did not include the annual staff health reports and Center Director verified they have been working since August 2022.
Plan of Correction:	Staff #2 has completed the stave health report form and that has been submitted
Standard #:	22.1-289.031-A-6
Description:	Repeat Based on observation and staff interviews, the center did not ensure the required aspects of the child day center's operations are described in a written statement were provided to the parents or guardians of the children in the center and made available to the general public. Evidence: The Center Director confirmed the following required aspects of the center /information was not in a written statement and made available to parents or the public as required. enrollment capacity public liability insurance.
Plan of Correction:	The public disclosure statement that contains our enrollment capacity an public liability insurance information has been posted. Pictures have been submitted
Standard #:	22.1-289.035-B-2
Description:	Repeat Based on record review and staff interviews, the center did not ensure, all staff had obtained a Criminal History Records Check Results (CRC) prior to the 1st day of employment.. Evidence: Staff #12 did not have a CRC. Center Director verified they have been working since August 2022.
Plan of Correction:	Staff #12 has had fingerprints done and is waiting for results
Standard #:	22.1-289.035-B-4
Description:	Based on record review and staff interviews, the center did not ensure, all staff obtained an out of state sex offender registry check and criminal history name check (CRC) prior to the first day of employment and a child abuse and neglect search request by the end of 30th day of employment for each state an individual has resided in the past 5 years prior to the 1st day of employment. Evidence: The following records were missing required out of state background checks 1.Staff #3 did not include results of a CRC, a sex offender check and a child abuse and neglect search for California where they had lived in the last five years. Center Director verified they have been working since August 2023. 2. Staff #10 did not include results of a CRC, a sex offender check and a child abuse and neglect search for Indiana where they had lived in the last five years. Center Director verified they have been working since August 2023.
Plan of Correction:	Staff #3 completed criminal check, also a sex offender and child abuse /neglect check w / CA and results have been submitted. Staff #10 has competed a CRC and results have been submitted . Staff #10 has submitted paperwork for Child Abuse and Neglect search w/ IN -waiting results
Standard #:	8VAC20-770-40-D-2
Description:	Repeat Based on a review of staff records and staff interviews, the provider did not ensure each staff member had obtained by their first day or employment a sworn statement of affirmation and by end of the 30th day of hire the results of the Central Registry (CPS) finding for the state of Virginia. Evidence: The following records were missing the required background checks 1.Staff #2 did not have a CPS check or a completed sworn statement. Center Director verified they have been working since September 2023. 2. Staff #3 did not have a CPS check. Center Director verified they have been working since August 2023. 3. Staff #4 did not have a CPS check. Center Director verified they have been working since August 2022. 4. Staff #5 did not have a CPS check. Center Director verified they have been working since September 2023. 5. Staff #8 did not have a CPS check. Center Director verified they have been working since August 2022. 6. Staff #9 did not have a CPS check. Center Director verified they have been working since August 2022. 7. Staff #10 did not have a CPS check or a completed sworn statement. Center Director verified they have been working since August 2023. 8. Staff #11 did not have a CPS check. Center Director verified they have been working since August 2022.
Plan of Correction:	Staff #2 has completed CPS Check-results are pending, sworn statement has been completed and signed. Staff #3 has completed CPS Check-results are pending Staff #4 has completed CPS Check-results are pending Staff #5 has completed CPS Check-haven't received results yet Staff #8 has completed CPS Check -results have been submitted Staff #9 has completed a CPS check. results have been submitted Staff #10 has completed a CPS Check- results are pending. A sworn statement has been completed, signed and dated Staff #11 has competed a CPS check and results have been documented