VIRGINIA DEPARTMENT OF SOCIAL SERVICES

LeafSpring School at Wyndham
5701 Wyndham Park Drive
Glen allen, VA 23059
(804) 360-2166

Current Inspector: LaTasha Smith (804) 588-2362

Inspection Date: May 3, 2019 and May 10, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-185 ADMINISTRATION. 22VAC40-185 STAFF QUALIFICATIONS AND TRAINING. 22VAC40-185 PHYSICAL PLANT. 22VAC40-185 STAFFING AND SUPERVISION. 22VAC40-191 Background Checks (22VAC40-191) 63.2(17) License & Registration Procedures

Technical Assistance:

n/a

Comments:

The licensing inspector conducted an unannounced inspection in response to a self-reported concern regarding supervision that occurred at the center on April 22, 2019. The Department was notified of the incident on April 24, 2019. The investigation was initiated on April 26, 2019 and completed on June 3, 2019. On May 03, 2019, the licensing inspector conducted an unannounced inspection from approximately 12:30pm until 2:00pm. Interviews were completed, observations were made in the center, and documentation was reviewed. On May 10, 2019, the inspector conducted additional interviews and follow-up activities at the center from approximately 11:20am until 11:40am. The preponderance of the evidence gathered during the investigation validates the self-reported incident. See the violation notice for more details. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the Violation Notice and return it to me within 5 business days from the date of receipt. Please specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standards, 2) measures to prevent the noncompliance from occurring again, and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). If you have any questions about this inspection, please contact the licensing inspector at (804) 662-9772.

Violations:

Standard #:	22VAC40-185-40-E
Description:	Based on a review of policies and procedures, interviews and a review of documentation, the center did not ensure that the center's activities and services were in compliance with the center's own policies and procedures related to supervision that are required by the standards. Evidence: 1) On 04/22/2019, Staff #1 and Staff #2 were supervising 17 three-year-old children in the Green Room. During interview on 05/03/2019, Staff #4 reported that the 17 children were left unsupervised at nap time from approximately 12:46pm until 1:42pm. 2) In a written statement dated 04/22/2019, Staff #2 stated ?I left on my break at 12:44 pm. I saw [Staff #1] sitting on a green chair next to the computer. She was working on her tablet. I returned to the room at 1:42pm. I saw that [Staff #1] was not in the room. I called the front desk to report the same. [Staff #4] answered the phone.? A review of Staff #2's time card confirms Staff #2 clocked out at 12:44pm and clocked back in at 1:42pm on 04/22/2019. 3) In a written statement, Staff #1 stated ?Once all the children were put down for nap. I sat at the chair and put my last student into COR. I got up from the chair waved by [sic] to my co-teacher and walked out the room. When I clocked in, I was called to the office and told that the classroom was left unattended.? A review of Staff #1's time card revealed Staff #1 clocked out at 12:46pm and clocked back in at 1:50pm on 04/22/2019. 4) Staff #1 and Staff #2 were unaware that the 17 children in their care were left unsupervised at nap time. The center?s Child Accountability policy states ?all children enrolled at LeafSpring School shall be safe and accounted for at all times.?
Plan of Correction:	Per the Center: "Upon review of the incident, internally and in conjunction with our licensing department, it was determined that Staff #1 and Staff #2 both were aware of the established accountability policy and procedures in place and acted outside the bounds of these established operational procedures. All staff are trained on these critical policies and procedures upon hire and annually thereafter. Furthermore, all school faculty/staff were immediately retrained in all accountability procedures, which required all faculty/staff to review and re-sign the school accountability policy, in conjunction with face to face retraining on school accountability procedures. Staff #1 is no longer employed with our school. All other individuals involved have received written counsel documented in their personal file. Site administration will continue to use the wealth of resources available to ensure compliance to all school policy and procedures, regulatory compliance, and accreditation compliance through our quality assurance processes."
Standard #:	22VAC40-185-340-F
Description:	Based on interview and documentation reviewed, the center did not ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff. Evidence: 1) Documentation reviewed on 05/03/2019 shows a total of 17, 3-year-old, children were in the care of Staff #1 and Staff #2 in the Green Room on 04/22/2019. It is estimated that the children were left out of sight and sound supervision of staff from 12:46pm to 1:42pm when Staff #1 and Staff #2 took an overlapping lunch break. 2) In a written statement dated 04/22/2019, Staff #3 stated "At 145 [sic] i [sic] heard [Staff #2] call [Staff #1]'s name. A minute after [Staff #2] said, "[Staff #3] is [Staff #1] over there?" i [sic] responded no and then i [sic] got up from the computer desk and asked [Staff #2] what was wrong..she [sic] responded, "I got back from my break and [Staff #1] wasn't here" I told her to call the front desk." 3) During interview on 05/03/2019, Staff #3 reported that the children in the Blue Room were in her care on 04/22/2019. Staff #3 reported she was not aware that Staff #1 and Staff #2 were not in the Green Room for a portion of nap time until Staff #2 reported it to her. The Blue Room is located next to the Green Room, but Staff #3 was not within actual sight and sound supervision of the children in the Green Room. Children under 10 years of age always shall be within actual sight and sound supervision of staff.
Plan of Correction:	Per the Center: "Upon review of the incident, internally and in conjunction with our licensing department, it was determined that appropriate sight and sound accountability procedures were in place, along with an established break schedule. All staff are trained on accountability procedures and break protocol upon hire and annually thereafter. Staff #1 and Staff#2 did not follow the established procedures. All school faculty/staff were immediately retrained in all accountability procedures, which required all faculty/staff to review and re-sign the school accountability policy, in conjunction with face to face retraining on school accountability procedures. Staff #1 is no longer employed with our school. All other individuals involved have received written counsel documented in their personal file. Site administration will continue to use the wealth of resources available to ensure compliance to all school policy and procedures, regulatory compliance, and accreditation compliance through our quality assurance processes."
Standard #:	22VAC40-185-350-E-4
Description:	Based on interviews and documentation reviewed, the center did not ensure compliance with ratios of staff to children as required. Evidence: 1) The licensing inspector reviewed the time card for Staff #1 and Staff #2 on 05/03/2019. The time card for Staff #1 shows that she clocked out at 12:46pm and clocked back in at 1:50pm on 04/22/2019. The time card for Staff #2 shows that she clocked out at 12:44pm and clocked back in at 1:42pm on 04/22/2019. 2) The licensing inspector reviewed the Rollcall Sheet for the Green Room on 05/03/2019. There were a total of 17 three-year-old children in care on 04/22/2019 during the times Staff #1 and Staff #2 clocked out. 3) During interview on 05/03/2019, Staff #4 reported that Staff #2 called the front desk to report that Staff #1 was not in the Green Room upon Staff #2's return from her lunch break. The ratio for children from three years to the age of eligibility to attend public school, five years by September 30, is one staff member for every 10 children. There were no staff present in the Green Room from approximately 12:46pm until 1:42pm.
Plan of Correction:	Per the Center: "Upon review of the incident, internally and in conjunction with our licensing department, it was determined that established ratios reflective of the Department of Social Services regulations were in place. All staff are trained on ratio management upon hire and annually thereafter. Staff #1 and Staff#2 did not follow the established school policies and procedures, which are reflective of the licensing standards. All school faculty/staff were immediately retrained in all accountability procedures, including ratio management, which required all faculty/staff to review and re-sign the school accountability policy, in conjunction with face to face retraining on school accountability and ratio management procedures. Staff #1 is no longer employed with our school. All other individuals involved have received written counsel documented in their personal file. Site administration will continue to use the wealth of resources available to ensure compliance to all school policy and procedures, regulatory compliance, and accreditation compliance through our quality assurance processes."