VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pittsylvania County Community Action- Elpis Center
823 Dearing Ford Road
Lynch station, VA 24571
(434) 369-2444

Current Inspector: Tara K Martin (804) 588-2371

Inspection Date: Feb. 3, 2020 and Feb. 4, 2020

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. 22VAC40-191 Background Checks (22VAC40-191) 63.2(17) License & Registration Procedures

Comments:

An unannounced renewal inspection was conducted on 02/03/2020 (on-site inspection) and 02/04/2020 (staff record review inspection). There were 33 children, ages 3 years-5 years, and 5 staff present during the inspection. The inspector reviewed 5 children's records, 5 staff records and 2 medications during the inspections. The children were observed in the following activities: in free choice/center play, during story time, in large motor play outside on the playground, during lunch and going down for nap time. The inspector reviewed the emergency preparedness plans, the updated injury prevention plan, the transportation requirements and the emergency supplies during the inspection. The inspector discussed playground equipment, nutrition and children's records with the staff. The inspector arrived for the on-site inspection at 10:45 a.m. and departed at 1:15 p.m. and arrived for the staff record review at 11:30 a.m. and departed at 1:30 p.m. If you have any questions, please contact Becky Forestier at 540-309-2835.

Violations:

Standard #:	22VAC40-185-130-A
Description:	Based on record review, document review and discussion with staff, the facility 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. Exemptions: Documentation of immunizations is not required for any child whose (i) parent submits an affidavit to the center, on the form entitled "Certification of Religious Exemption," stating that the administration of immunizing agents conflicts with the parent's or child's religious tenets or practices, or (ii) physician or a local health department states on a MCH 213B or MCH 213C Form or other Department of Health-approved form that one or more of the required immunizations may be detrimental to the child's health. Evidence: The record for Child #3 did not contain documentation that the child has received the immunizations required by the State Board of Health nor did the record contain the required "Certification of Religious Exemption" affidavit that is required when a child is not immunized; the record contained a "Refusal to Vaccinate" form.
Plan of Correction:	The program director will provide the Certificate of Religious Exemption to the parent and request the parent to complete the form.
Standard #:	22VAC40-185-160-C
Description:	Based on record review and discussion with staff, the facility failed to ensure that staff resubmit TB test results at least every two years from the date of the first initial screening or testing. Evidence: The record for Staff #3 contained a TB test/screening dated 08/18/2017. There was not documentation of a follow-up TB test/screening for 2019.
Plan of Correction:	Staff #3 has requested documentation of the test/screening be sent to the administrative office.
Standard #:	22VAC40-185-270-A
Description:	Based on observations and discussion with the staff, the facility 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 lock on the first stall in the girls restroom was broken and created a sharp edge that could cut skin. 2. The swing beam on the red/yellow/blue piece of playground equipment was observed moving back and forth while children were swinging on the swings during the 02/03/2020 inspection. Closer investigation revealed that 2 of the 3 bolts/screws used to hold the swing beam in place on the structure were missing. 3. The slide on the red/yellow/blue piece of playground equipment was missing 1 of the 2 screws that holds the slide onto the structure; children were observed using the slide during the 02/03/2020 inspection. 4. The paint on the red/yellow/blue piece of playground equipment was peeling. 5. The boards of the slide platform on the red/yellow/blue piece of playground equipment were not secured tightly; the boards were loose and would bend under the pressure of being stood on. 6. Children were observed using the red/yellow/blue piece of playground equipment during the 02/03/2020 inspection.
Plan of Correction:	The lock was removed during the 02/03/2020 inspection. The piece of playground equipment was closed during the inspection and will remain closed. The program director will request that the piece be removed.
Standard #:	22VAC40-185-280-B
Description:	Based on observations and discussion with staff, the facility failed to ensure that hazardous substances, such as cleaning materials, shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: The storage closet in the boy's restroom was unlocked during the 02/03/2020 inspection. The storage closet contained multiple gallons of Clorox, multiple aerosol spray cans of Lysol and various other cleaning materials.
Plan of Correction:	The staff will be instructed to check the closet daily to ensure it is locked.
Standard #:	22VAC40-185-550-H
Description:	Based on document review and review of the bus, the facility failed to prepare a document containing local emergency contact information, potential shelters, hospitals, evacuation routes, etc. that pertain to each site frequently visited or routes frequently driven by center staff for center business (such as field trips, pickup/drop off of children to or from schools, etc.) This document must be kept in vehicles that centers use to transport children to and from the center. Evidence: There was not a document containing local emergency contact information, potential shelters, hospitals, evacuation routes, etc., that pertain to each site frequently visited or of routes frequently driven by center staff for center business on Bus 10. Bus 10 is used daily for the pickup and drop off of children. Documentation on Bus 10 confirmed that Bus 10 had been driven on the morning of 02/03/2020.
Plan of Correction:	The document will be re-done today.