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Courthouse Academy
3217 Monet Drive
Virginia beach, VA 23453
(757) 368-0368

Current Inspector: Rene Old (757) 404-1784

Inspection Date: Dec. 19, 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

Technical Assistance:
Two shelter-in-place practice drills are required annually.

Comments:
An unannounced monitoring inspection was conducted on 12/19/2019 from 11:15 am - 3:25 pm. At the time of the tour there were 158 children, ages infant - four years, in care with 27 staff. Children were observed during lunch and nap. Departure was additionally observed.
Records were reviewed for eight children and 12 staff.
Violations were observed in six parts of the CDC standards and background checks. These violations are listed on the violation notice and were reviewed with the program director at the conclusion of the inspection.

Violations:
Standard #: 22VAC40-185-130-A
Description: Based on record review and interview, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.

Evidence:
1. Immunization documentation was not on file for child 6 who was in care during the inspection.
a. Child 6 has an enrollment date of 12/03/2019.
2. Administrative staff confirmed that immunization information had not been obtained for child 6.

Plan of Correction: The parent will be asked at pick-up today to provide documentation of current immunizations as soon as possibe but no later than January 2, 202 when the school resumes operation.

Standard #: 22VAC40-185-130-B
Description: Based on record review and interview, the center failed to obtain documentation of additional immunizations once every six months for children under the age of two years.

Evidence:
1. The most recent immunizations for child 1, age 11 months, were administered on 03/08/2019.
2. The most recent immunizations for child 2, age 12 months, were administered on 04/03/2019.
3. The most recent immunizations for child 4, age 12 months, were administered on 03/07/2019.
4. Administrative staff confirmed that documentation of updated immunizations had not been obtained for these children who were in care during the inspection.

Plan of Correction: Each parent will be asked at pick-up today to provide documentation of additional immunizations as soon as possible but no later than January 2, 202 when the school resumes operation.

Standard #: 22VAC40-185-140-A
Description: Based on record review and interview, the center failed to ensure that each child shall have a physical examination by or under the direction of a physician before the child's attendance or within one month after attendance.

Evidence:
1. There is no documented physical on file for child 5 who was in care during the inspection.
a. Child 5 has an enrollment date of 12/04/2018.
2. Administrative staff verified that child 5 did not have documentation of a physical exam on file.

Plan of Correction: The parent of child 5 will be asked to provide a current physical within 30 days.

Standard #: 22VAC40-185-60-A
Description: Based on record review, the center failed to ensure that children's records contained all of the required elements.

Evidence:
1. The enrollment record for child 1 lacked work phone number for one parent's place of employment.
a. The record also lacked a phone number for the second emergency contact.
2. The enrollment record for child 2 lacked a work phone number for both parent's place of employment.
3. The enrollment record for child 3 lacked a work phone number for one parent's place of employment.
4. The enrollment record for child 4 lacked a work phone number for one parent's place of employment.
a. The record also lacked a phone number for the second emergency contact.
5. The enrollment record for child 5 lacked a work phone number for one parent's place of employment.

Plan of Correction: Most of the missing information was obtained during the inspection and documented in children's records.
Each parent will be asked to provide the required information at pick-up today.

Standard #: 22VAC40-185-270-A
Description: Based on observation, the center failed to ensure that areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition.

Evidence:
1. The fire/emergency exit door way in the toddler/two-year old classroom (room 9) has been blocked by a cabinet in front of a closed floor to ceiling room partition. On the other side of the partition two stacks of chairs had been placed directly in front of the partition.
2. The fire/emergency exit door way in the two-year old classroom (room 22) has been blocked by home living furniture in front of a closed and locked floor to ceiling room partition. On the other side of the partition two stacks of chairs had been placed directly in front of the partition.
3. A child in room 13 was observed napping on a cot that had been placed directly in front of the emergency/fire exit door to the outside.
4. A shelving unit measuring approximately three feet x three feet in room 12 had not been secured to the wall creating a toppling hazard. The shelf moved when pulled on and multiple items had been placed on top of this shelf to include a fan.
5. Three infants were observed napping on loose crib sheets. Loose sheets are a suffocation hazard.
6. Two loose and accessible cords were observed on the floor in the infant classroom. These cords, which were attached to the radio and swing, measured approximately 25 inches in length and are an entanglement hazard.

Plan of Correction: 1. The emergency exits in room 9 and 22 will be cleared this evening.
2. Staff will be reminded that cots may not be placed in the fire / emergency exit door way.
3. The shelving unit was removed.
4. Tight fitting crib sheets will be obtained.
5. The cords will be removed and placed in such a way as to make them inaccessible to children.

Standard #: 22VAC40-185-270-C
Description: Based on observation and interview, the center failed to ensure that in inside areas occupied by children, the temperature shall be maintained no lower than 68F.

Evidence:
1. The thermostat in two preschool classrooms indicated a temperature of 67F.
2. The thermostat in a third preschool classroom indicated a temperature of 65F.

Plan of Correction: The thermostat in these classrooms will be adjusted to maintain a temperature of at least 68F.

Standard #: 22VAC40-185-330-B
Description: Based on a review of the facility playground the center failed to ensure that when playground equipment is provided the fall zone shall encompass sufficient area to include the child's trajectory in the event of a fall when the equipment is in use.
*The use zone requirement for stationary equipment is six feet on all sides of the equipment.

Evidence:
1. The climbing play structure located on the two-year old playground has been placed 42 inches from the fence on on side and 32 inches from the tricycle-on-a-track on the other side.

Plan of Correction: This play structure will be moved to ensure a fall zone of six feet on all sides.

Standard #: 22VAC40-185-350-E-1
Description: Based on observation, the center failed to ensure that the following ratios of staff to children are required wherever children are in care:
For children from birth to the age of 16 months: one staff member for every four children.

Evidence:
1. One staff was observed with five infants and one toddler during nap time at approximately 12:00 pm.
2. The program director and classroom staff confirmed that there was only one staff present for this group of children during nap.

Plan of Correction: Going forward two staff will be placed with this class during nap.
It was our understanding that the ratio of 1:4 could double during nap time if the children were older infants.

Standard #: 22VAC40-185-380-A
Description: Based on observation the center failed to ensure that there shall be a posted daily schedule that allows for flexibility as children's needs require.

Evidence:
1. There was no posted daily schedule in three-year old classroom 17.
2. Classroom staff confirmed that the daily schedule was not posted.

Plan of Correction: The daily schedule will be posted.

Standard #: 22VAC40-185-430-C
Description: Based on observation, the center failed to ensure that play equipment shall have no protrusions.

Evidence:
1. A metal bolt was observed protruding from the bottom of the green stationary car on the two-year old playground.
a. The bolt measured nine treads.

Plan of Correction: This will be repaired during the holiday break.

Standard #: 22VAC40-185-500-B
Description: Based on observation, the center failed to ensure that the diapering area shall be a nonabsorbent surface for diapering and shall be used only for diapering or cleaning children.

Evidence:
1. A box of powdered donuts was observed sitting on the diaper changing table in the infant classroom at approximately 11:30 am.
2. A rip was observed on the diapering pad in one classroom. A tear on the surface allows for bacteria to seep inside of the pad.

Plan of Correction: The donuts were removed during the inspection and staff will be reminded not to place any item on the changing table.
A new diapering pad will be obtained.

Standard #: 22VAC40-185-510-C
Description: Based on medication review, the center failed ensure that long-term prescription drug use and over-the-counter medication may be allowed with written authorization from the child's physician and parent.

Evidence:
1. One over-the-counter ointment lacked written authorization from the child's physician.
a. The written consent form the child's parent was dated 08/11/2019 and was authorized on a form for diaper ointment.
b. This ointment has been applied three times according to the diaper ointment log.
2. One prescription emergency medication lacked written consent form the parent of child 7.
a. The physician authorization was dated 05/28/2019 and the medication was administered twice on 07/11/2019.
3. There was no written authorization for one prescription emergency medication for child 8.
a. The physician authorization was dated 04/23/2019 and this medication has not been administered.

Plan of Correction: Current parent authorizations will be obtained today at pick-up.

Standard #: 22VAC40-185-510-E
Description: Based on observation, the center failed to ensure that medication shall be labeled with the child's name.

Evidence:
One tube of over-the-counter medication was not labeled with the child's name.

Plan of Correction: The medication was labeled during the inspection.

Standard #: 22VAC40-185-560-G
Description: Based on observation, the center failed to ensure that when food is brought from home the food container shall clearly dated and labeled in a way that identifies the owner.

Evidence:
1. One bag of frozen breast milk was not dated and labeled to identify the owner.
2. Classroom staff stated they did not know which child the breast milk belonged to.

Plan of Correction: This will not be fed to any child.
If we can not determine who the breast milk belongs to - it will be discarded.

Standard #: 22VAC40-191-60-B
Description: Based on record review, the center failed to ensure that an employee of a licensed facility must not be employed until the facility has the person's sworn statement or affirmation.

Evidence:
1. There was no sworn statement or affirmation on file for staff 4 who was working in the facility during the inspection.
a. Staff 5 has a hire date of 08/19/2019.
2. Administrative staff confirmed that staff 5 had not completed a sworn statement or affirmation.

Plan of Correction: Staff 4 completed a sworn statement or affirmation during the inspection.

Standard #: 63.2(17)-1721.1-B-3
Description: Based on record review and interview, the center failed to obtain a copy of the results of a search of the central registry maintained by any other state in which the individual has resided in the preceding five years for any founded complaint of child abuse or neglect against him.

Evidence:
1. There is not central registry check on file from the State of Washington for staff 1.
a. Staff 1 indicated that she resided in the State of Washington within the past five years.
b. Staff 1 has an employment date of 07/30/2019.
2. There is no central registry check on file from the State of Colorado for staff 2.
a. Staff 2 indicated that she resided int he State of Colorado within the past five years.
b. Staff 2 has an employment date of 08/26/2019.
3. There is no central registry check on file from the State of Connecticut for staff 3.
a. Staff 3 indicated that she resided int he State of Connecticut within the past five years.
b. Staff 3 has an employment date of 07/30/2019.

Plan of Correction: All of these will be requested no later than Monday, December 23, 2019.

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.

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