VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Right at School at Virginia Avenue Elementary
550 Virginia Avenue
Winchester, VA 22601
(540) 583-8149

Current Inspector: Barbara Workman (540) 430-9257

Inspection Date: Oct. 23, 2023

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care Provisions and Emergencies 8VAC20-780 Special Services. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Comments:

A non-mandated monitoring inspection was conducted on October 23, 2023 from 3:40 P.M.-5:30 P.M. There were 16 children present, ranging in ages from five years of age to 12 years of age, with two staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of five child records and two staff records were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the Licensing Inspector within 5 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions or concerns please contact the Licensing Inspector at 540-430-9257.

Violations:

Standard #:	22.1-289.011-F
Description:	Based on a review of required posted information, the center failed to ensure that the summary or violation notice from the last inspection shall be posted. Evidence: 1. The inspection summary from the last inspection on August 9, 2023 was not posted. 2. The inspection report was emailed to administration on August 11, 2023.
Plan of Correction:	These inspections will be posted immediately and will be verified monthly by the Area Manager during visits to the schools.
Standard #:	22.1-289.035-B-4
Description:	Based on a review of staff records, the facility failed to obtain out-of-state background checks on individuals who have resided outside of Virginia within the past five years. Evidence: 1. Staff #1 indicated on the sworn disclosure statement dated 07/27/2023 that they had lived in one other state within the past five years. 2. Staff #1's date of hire was 08/10/2023 there was not a record of the out of state sex offender name completed prior to hire, and there was not a record of an out of state child abuse and neglect check sent out by the 30th date of hire. 3. Administration verified that the out-of-state background checks were not completed.
Plan of Correction:	Three employees were advised. Two are in the process and one has been submitted. As new employees are hired, if they are from another state, they will submit their request during the on-boarding process.
Standard #:	8VAC20-770-60-C-2
Description:	Based on review of staff records, the center failed to obtain central registry finding within 30 days of employment. Evidence: 1. Staff #1's date of hire 08/10/2023. There was not a completed central registry finding in the file. 2. Staff #2's date of hire was 08/09/2023. There was not a completed central registry finding in the file. 3. Administration verified that they did not have the completed central registry finding in their records, and had not checked on the status of the record checks.
Plan of Correction:	All staff currently have either been approved or are in the application process. As new hires come onboard, Area Manager will continually submit CRS applications immediately upon hire.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of children records, the facility failed to ensure that all required information was in the children records. Evidence: 1. Child #1's record did not contain a complete address for the two designated people to call in an emergency if the parent cannot be reached. 2. Child #2's record did not contain the date of enrollment, and two address for the two designated people to call in an emergency if the parent cannot be reached. 3. Child #3's record did not contain the name, address, and phone number of the father. The father was listed on pick up list, and did not contain the name, home address, and phone number of each parent who has custody. 4. Child #4's record did not contain the date of enrollment, the complete address, home phone and business phone for the father, the business phone for the mother, and the two designated people to call in an emergency did not include complete addresses.
Plan of Correction:	All files have been reviewed and parents are being informed of the missing items. They have been asked to update and return them to us asap. We will verify completeness of forms in the future before the child is admitted to the program.
Standard #:	8VAC20-780-70
Description:	Based on a review of staff records, the facility failed to ensure that all required information was in the staff record. Evidence: Staff #2's file was missing the date of employment, name address, and telephone number of a person to be notified in an emergency, and documentation of orientation being completed was missing the date.
Plan of Correction:	All staff files will be brought up-to-date by 11/30/23 and will be reviewed regularly by the Area Manger to maintain accuracy and completeness.
Standard #:	8VAC20-780-280-B
Description:	Based on observation, the center failed to ensure that all hazardous materials were kept in a locked location. Evidence: 1. On the shelf located in the cafeteria there was a container of Nilosorb Deodorizing Liquid Spill Absorbent, and two spray bottles of HB Quat Concentrate Disinfectant Cleaner. 2. The manufacturer labeled stated "keep out of reach of children" and "DANGER Hazardous to humans and domestic animals. 3. The shelf is an open location and accessible to children.
Plan of Correction:	Emailed principal and had all the schools chemicals removed from the area that children are present. Will inspect daily to insure they are not present.
Standard #:	8VAC20-780-540-E
Description:	Based on review of nonmedical emergency supplies, the center failed to ensure that there was a battery operated radio at the site. Evidence: 1. There was not a battery operated radio on site. 2. Staff #1 verified she could not locate a battery operated radio.
Plan of Correction:	Effective 11/1/2023 all centers were issued a battery powered radio and there will be a monthly check of supplies by the Area Manager during visits.
Standard #:	8VAC20-780-550-D
Description:	Based on a review of evacuation drills, the center failed to implement monthly practice evacuation drills. Evidence: 1. The program opened in August 2023. There was no documentation that evacuation drills had been completed for August or September 2023. 2. Staff #1 verified that monthly evacuation drills had not been completed.
Plan of Correction:	An email was sent to Program Manager at VACDES requiring a documented drill every month. Report to be kept in their logs and a copy sent to the Area Manager for verification.