VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Happy Feet Early Learning and Child Center
37 Ellsworth Street
Martinsville, VA 24112
(276) 403-4183

Current Inspector: Rebecca Forestier (540) 309-2835

Inspection Date: Oct. 10, 2018

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. 63.2 Licensure and Registration Procedures 22VAC40-191 Background Checks (22VAC40-191)

Comments:

An unannounced monitoring inspection was completed on 10/10/2018. Present during the inspection were 16 children, ages 2 months-3 years, 4 staff providing direct care and supervision and 1 support staff (the program administrator). The inspector reviewed 5 children's records and 4 staff records. The facility staff confirmed that medication is not administered at this facility. Children were observed in the following activities: during breakfast, during free choice play, being read to, and during lunch. Infants were observed being fed and allowed to sleep on demand. Diapering was also observed. The inspector reviewed the emergency procedures and emergency supplies. The inspector discussed the following with various site staff: attendance requirements, children's allergies, nutrition, and program administration. The inspector offered to provide a licensing standards training session for the staff at the program's convenience. The inspector arrived for the inspection at 8:50 a.m. and departed at 2:45 p.m. If you have any questions, please contact Becky Forestier at 540-309-2835.

Violations:

Standard #:	22VAC40-185-160-A
Description:	Based on record review, the facility failed to ensure that all staff members submit documentation of a negative tuberculosis screening no later than 21 days after employment. Evidence: On 10/10/2018 Staff #1 was unable to provide documentation of a negative tuberculosis screening for the following staff: 1. Staff #2; the documented date of hire for Staff #2 was 03/06/2018. 2. Staff #3; the documented date of hire for Staff #3 was 05/19/2018. 3. Staff #5; the documented date of hire for Staff #5 was 07/16/2018.
Plan of Correction:	After receiving the fingerprints, the provider will give employees 21 days to get a TB test.
Standard #:	22VAC40-185-160-C
Description:	Based on record review, the facility failed to ensure that staff members shall obtain and submit the results of a follow-up tuberculosis screening at least every two years from the date of the first initial screening or testing. Evidence: The record for Staff #1 contained a tuberculosis screening last completed 08/28/2015; no 2017 screening was found in the record.
Plan of Correction:	Staff #1 will get a TB test.
Standard #:	22VAC40-185-40-D
Description:	Based on observations and discussion with the staff, the facility failed to ensure that the license shall be posted in a place conspicuous to the public. Evidence: The license was not posted. Staff #1 confirmed that the license was not posted; corrected on-site.
Plan of Correction:	The provider will make sure the license stays posted.
Standard #:	22VAC40-185-60-A
Description:	Based on record review and discussion with the staff, the facility failed to ensure that the separate record for each enrolled child contained all elements required by the standards. Evidence: Specific information that was missing/not contained in the record was as follows: 1. Sex of the child- Child #2 2. Name, address and phone number of two designated people to call in an emergency if a parent cannot be reached: Child #1- only contained one contact, Child#2 ? no address information listed for either contact 3. Name of persons authorized to pick up the child- Child #2 4. Allergies and intolerance to food, medication , or any other substances, and actions to take in an emergency situation- Child #1 5. Health information as required by 22VAC40-185-130 through 22VAC40-185-150- Child #1, Child #2, Child #3 6. Written agreements between the parent and the center as required by 22VAC40-185-90- Child #2 7. Previous child day care attended by the child- Child #1, Child #2 8. Name of any additional programs or schools that the child is concurrently attending and the grade or class level- Child #1, Child #2, Child #3 9. Documentation of viewing proof of the child?s identity and age- Child #2 10. First date of attendance- Child #1, Child #2, Child #3, Child #5
Plan of Correction:	The provider will update all records to make sure all information is in the record.
Standard #:	22VAC40-185-70-A
Description:	Based on record review and discussion with the staff, the facility failed to ensure that staff records contain all elements required by the standards. Evidence: 1. The record for Staff #2 did not contain the name, address and telephone number of a person to be notified in an emergency. 2. The record for Staff #3 did not contain written information to demonstrate that the individual possesses the education, staff development, certification and experience required by the job position documented in the record. 3. Staff #1 confirmed that there was no record available for Staff #4; Staff #4 was observed in the role of Cook and Program Lead in the Infant Room on 10/10/2018. 4. The record for Staff #5 did not contain written information to demonstrate that the individual possesses the experience required by the job position documented in the record.
Plan of Correction:	The provider will review the information, get the information needed and get the required training in place and place into the record.
Standard #:	22VAC40-185-80-A
Description:	Based on observation, review of the attendance record and discussion with the staff, the facility failed to keep a written record of children in attendance each day. Evidence: The attendance record for the 2yr-3yr old class did not document children in attendance for 10/09/2018.
Plan of Correction:	The provider will make sure attendance is taken upon arrival everyday.
Standard #:	22VAC40-185-210-A
Description:	Based on observations, record review and discussion with the staff, the facility failed to ensure that staff identified as program leaders meet at least one of the qualification required by the standards. Evidence: 1. Staff #3: The record had a documented job title of Program Lead. Staff #3 was observed in the role of Program Lead for the 2-3 year old class on 10/10/2018; Staff #3 stated she was the lead for the class. The facility failed to demonstrate that Staff #3 met one of the Program Lead qualifications. 2. Staff #4: Staff #1 confirmed that there was no record for Staff #4. Staff #4 was observed in the role of Program Lead for the Infant Class on 10/10/2018. The facility failed to demonstrate that Staff #4 met one of the Program Lead qualifications. 3. Staff #5: The record had a documented job title of Program Lead. Staff #5 was observed in the role of Program Lead for the Infant Class on10/10/2018. The facility failed to demonstrate that Staff #5 met one of the Program Lead qualifications.
Plan of Correction:	The provider will plan to make reference calls, get the necessary documents to verify program lead and/or get the staff trained.
Standard #:	22VAC40-185-240-D-5
Description:	Based on record review and information provided by staff, the facility failed to 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 of children. Evidence: The facility failed to demonstrate that at least one staff member on duty had obtained, within the last three years, instruction in performing the daily health observation of children. Staff #1 provided documents for review on 10/10/2018; there was no documentation provided to demonstrate that any of the 5 staff members present on 10/10/2018 has received instruction in performing the daily health observation of children within the last three years.
Plan of Correction:	The provider will get staff into a class and will file the training documents.
Standard #:	22VAC40-185-280-D
Description:	Based on observations and discussion with the staff, the facility failed to ensure that cleaning and sanitizing materials shall be stored in areas physically separate from food. Evidence: The bottom shelf of the storage cabinet in the first classroom on the right as you enter the building, contained an aerosol spray can of Dollar General Disinfectant, a plastic spray bottle labeled "Bleach and Water" and a second plastic spray bottle containing a liquid solution that was unlabeled. Also located on the bottom shelf of the cabinet was a small plastic storage basket labeled with Child #6's name that contained a variety of baby food containers, a box of Gerber Lil' Biscuits, a container of Gerber Puffs and a container of Bitty Bites.
Plan of Correction:	The cabinet was cleaned and corrected. Staff were retrained.
Standard #:	22VAC40-185-280-G
Description:	Based on observations and discussion with the staff, the facility failed to ensure that if hazardous substances are not kept in original containers, the substitute container shall clearly indicate their contents. Evidence: The bottom shelf of the storage cabinet in the first classroom on the right as you enter the building, contained an unlabeled plastic spray bottle containing a liquid solution. Staff #1 stated that she was not sure as to the contents of the substitute unlabeled container.
Plan of Correction:	The provider retrained the staff, reminding them to use soap/water and bleach/water only, but if another cleaner was used, they were trained to label the bottle.
Standard #:	22VAC40-185-320-B
Description:	Based on observations and discussion with the staff, the facility failed to ensure that each restroom area provided for children shall be equipped with soap, toilet paper and disposable towels or an air dryer within reach of children. Evidence: The restroom on the main level of the facility did not contain disposable towels or an air dryer. Children were observed using that restroom on 10/10/2018.
Plan of Correction:	The provider will contact the paper towel supplier to get more of the paper towels for the paper towel dispenser.
Standard #:	22VAC40-185-350-E-1
Description:	Based on observations and discussion with staff, the facility failed to ensure that whenever children are in care, the staff to child ratio is met for children from birth to the age of 16 months, which is one staff member for every four children. Evidence: 1. There were 5 children in the infant room on 10/10/2018. 2. The youngest child in the infant room was 2 months old; requiring a staff to child ratio of one staff member for every four children. 3. Staff #5 confirmed that she was aware that the ratio was not met on 10/10/2018 and further stated "every day", in reference to the ratio not being met.
Plan of Correction:	To make sure to stay within ratio, the provider will re-send memos to parents regarding calling in before 10:00 a.m. if needing care to make sure that there is enough staff. The parent will be asked to stay until another staff arrives.
Standard #:	22VAC40-185-500-A
Description:	Based on observations and discussion with the staff, the facility failed to ensure that staff shall wash their hands with soap and running water before and after helping a child use the toilet or a diaper change, after the staff member uses the toilet, after any contact with body fluids and before feeding or helping children with feeding. Evidence: Staff #2 was observed changing a child's soiled clothing on the changing table of the 2yr-3yr classroom. Staff #2 did not wash their hands after changing the child?s clothing.
Plan of Correction:	The provider held a staff meeting and retrained staff on hand washing and will continue to remind the staff.
Standard #:	22VAC40-185-570-C
Description:	Based on observations, review of records and discussion with the staff, the facility failed to maintain a record of each child on formula that contained the brand of formula used by the child and the child's feeding schedule. Evidence: 1. There was no formula type listed on the form for Child #7, "baby food" was the only type of food listed on the form; Staff #5 confirmed that Child #7 was on formula. 2. There was no record of the formula type or feeding schedule for Child #8, a child enrolled in the infant room.
Plan of Correction:	Parents will fill out the required infant log for licensing.
Standard #:	22VAC40-191-60-B
Description:	Based on observations, record review and discussion with the staff, the facility failed to ensure that no person may be employed until the agency has the persons completed sworn statement or affirmation. Evidence: 1. Staff #2: The personnel record for Staff #2 did not contain a completed sworn statement or affirmation, the record for Staff #2 has a documented hire date of 03/06/2018; Staff #2 was observed working in a classroom on 10/10/2018. 2. Staff #4: Staff #1 confirmed that Staff #4 did not have a completed sworn statement or affirmation; Staff #4 was observed working in the kitchen and working alone in the infant room on 10/10/2018.
Plan of Correction:	The provider will make sure that the Sworn Statement is attached to all applications and will be completed at that time.
Standard #:	22VAC40-191-60-C-2
Description:	Based on observations, record review and discussion with staff, the facility failed to obtain the findings from a search of the central registry within 30 days of employment. Evidence: 1. Staff #2: The personnel record for Staff #2 did not contain the findings of a search of the central registry, the documented hire date for Staff #2 was 03/06/2018; Staff #2 was observed working in a classroom on 10/10/2018. 2. Staff #3: The record for Staff #3 did not contain the finding of a search of the central registry, the documented hire date for Staff #3 was 05/19/2018; Staff #3 was observed working in a classroom on 10/10/2018. 3. Staff #4: Staff #1 stated that Staff #4 had offered to come in and help out as needed. Staff #1 confirmed that there was no staff record for Staff #4, Staff #1 confirmed that there had not been any background checks submitted for Staff #4; Staff #4 was observed working in the kitchen and working alone in the infant room on 10/10/2018. 4. Staff #5: The record for Staff #5 did not contain the findings of a search of the central registry, the documented date of hire Staff #5 was 07/16/2018; Staff #5 was observed working in the classroom on 10/10/2018. The original notarized copy of the Virginia Department of Social Services Central Registry Release of Information Form was still in the personnel record and had not been sent to the Office of Background Investigations.
Plan of Correction:	The search of the central registry will be mailed with 7 days of hire. All current staff's will be mailed immediately.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observations and discussion with the staff, the facility failed to ensure that the findings of the most recent inspection shall be posted on the premises. Evidence: 1. The most recent inspection was conducted on 04/23/2018; the facility failed to post the inspection summary and violation notice from that inspection. 2. Staff #1 stated she did not know what happened to the documents from the 04/23/2018 inspection. 3. Page 1 of 2 from the 12/15/2017 Violation Notice was the only document posted.
Plan of Correction:	The provider will post updated documents upon receipt.
Standard #:	63.2-1720.1-A
Description:	Based on record review and discussion with staff, the facility failed to obtain a repeat search of the central registry on employees as required by the Code of Virginia. Evidence: The most recent search of the central registry for Staff #1 was dated 03/18/2014; no 2017 update was found in the record.
Plan of Correction:	The provider will complete, get notarized and mail today.
Standard #:	63.2-1720.1-B-2
Description:	Based on observations, record review and discussion with staff, the facility failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia. Evidence: 1. Staff #2: The personnel record for Staff #2 had a documented hire date of 03/06/2018; the fingerprint eligibility letter was dated 03/16/2018. Staff #2 was employed before the facility received the fingerprint eligibility letter. 2. Staff #3: The personnel record for Staff #3 had a documented hire date of 05/19/2018, there was no fingerprint eligibility letter on record for Staff #3; Staff #3 was observed working in a classroom on 10/10/2018. Staff #3 was employed before the facility received the fingerprint eligibility letter. 3. Staff #4: Staff #1 stated that Staff #4 had offered to come in and help when needed. Staff #1 stated that background checks have not been submitted for Staff #4; Staff #4 was observed working in the kitchen and working alone in the infant room on 10/10/2018. 4. Staff #5: The personnel record for Staff #5 has a documented hire date of 07/16/2018; the fingerprint eligibility letter was dated 07/25/2018. Staff #5 was employed before the facility received the fingerprint eligibility letter.
Plan of Correction:	Moving forward, the provider will make sure to have received the fingerprints back to more forward with hiring and orientation. All fingerprints will be printed and filed within 24 hours.