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Mary Bethune Academy
2249 Halifax Street
Lynchburg, VA 24501
(434) 847-4221

Current Inspector: Victoria E Dawson (540) 309-2674

Inspection Date: March 4, 2019

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)
63.2(17) License & Registration Procedures

Comments:
An unannounced monitoring inspection was completed on 3/4/19. There were 38 children present in four groupings. Two as needed medications were reviewed. The inspector arrived at the center at 10:00 am and departed at 3:30 pm. The children were observed during free time in the classrooms, during lunch, and during nap.

Violations:
Standard #: 22VAC40-185-130-B
Description: Based on record review, the center failed to ensure that documentation was obtained of additional immunizations once every six months for children under the age of two years. Evidence: 1. The last documentation of an immunization for child #6 was 7/13/18. The child was four months old at that time. There has not been any additional documentation of immunizations obtained for child #6 since that time. The child is now 11 months old.

Plan of Correction: The staff will talk with the parent to get documentation of the child's updated immunizations.

Standard #: 22VAC40-185-160-A
Description: Based on record review, the center failed to ensure that each staff member had documentation of a completed tuberculosis (TB) test within 21 days after employment if not completed 12 months prior to employment. Evidence: 1. Staff #2 with a hire date of 10/8/18 did not have documentation of a completed TB test.

Plan of Correction: The staff will submit a copy of the completed test.

Standard #: 22VAC40-185-60-A
Description: Based on record review, the center failed to ensure that all required information was documented in each child's record. Evidence: 1. The record of child #2 was missing the following required information: work phone numbers for the mother and the father of the child, a complete address for one of two emergency contacts, allergies - if any. 2. The record of child #3 was missing the child's grade level. There was a school documented that the child attends but no grade level. There was no physician's phone number for child #3. 3. The record of child #5 was missing the following required information: the mother's work phone number, a second emergency contact person's name, address, and phone number, the child's physician's phone number. 4. The record of child #6 was missing the phone number for one of two emergency contacts. 5. The record of child #7 was missing a complete address for one of two emergency contacts for the child.

Plan of Correction: The information will be documented in each child's file.

Standard #: 22VAC40-185-70-A
Description: Based on record review, the center failed to ensure that all information required to be documented in a staff record was completed prior to employment/volunteering. Evidence: 1. The record of staff #5 was reviewed. According to the staff person and the person in charge at arrival of the inspector, it was this staff person's first day. Later during the inspection, the center director stated that this staff person was volunteering today. There were no references documented for this staff person that are required prior to employment or volunteering. 2. The record of staff #6 was reviewed. The documented start date for staff #6 was 10/15/18. The references for staff #6 were dated 10/16/18. References are required prior to employment. 3. The record of staff #4 was missing written information to demonstrate that the individual possesses the education, orientation training, staff development, certification, and experience required by the job position. The staff person would require education requirements beyond high school in order to be qualified for the job position.

Plan of Correction: All required information for staff records will be completed as required.

Standard #: 22VAC40-185-550-D
Description: Based on record review and interview, the center failed to ensure that two shelter-in-place (tornado) drills were practiced each year. Evidence: 1. The documentation for emergency drills for 2018 was viewed. There was one shelter-in-place drill observed documented for the year. 2. The director stated that one was required to be done.

Plan of Correction: Drills will be practiced and documented as required.

Standard #: 22VAC40-185-550-F
Description: Based on observation, the center failed to ensure that at each telephone there were emergency numbers posted at the phone. Evidence: 1. There was a phone observed on the bulletin board at the entrance to the kitchen. There were no emergency number (911 and poison control are required) observed.

Plan of Correction: Emergency numbers will be posted.

Standard #: 22VAC40-185-560-F
Description: Based on observation and interview, the center failed to ensure that the menu for the center provided meals and snacks was posted. Evidence: 1. The month of February menu was observed to be posted. The menu for the week of March 4 was not observed. 2. The director told the inspector that she was working on the menus and they would be posted once they are complete.

Plan of Correction: The menus will be posted once they are complete.

Standard #: 63.2(17)-1720.1-A
Description: Based on record review, the center failed to ensure that no staff was hired for compensated employment prior to the completion of a fingerprint background check. Evidence: 1. Staff #6 record had a documented start dated of 10/15/18. The date that the fingerprint background check was completed was 10/17/18.

Plan of Correction: The director will make sure that fingerprints are received prior to hire.

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.

Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. Eligible child care facilities must be fully licensed, licensed exempt and a VDSS subsidy vendor, or a voluntary registered day home and a VDSS subsidy vendor. Only programs enrolled in Virginia Quality will display a rating. Virginia Quality contact information for your region is available at the following link Regional Contacts.

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