VIRGINIA DEPARTMENT OF SOCIAL SERVICES

University Montessori School
1034 Reservoir Road
Charlottesville, VA 22903
(434) 977-0583

Current Inspector: Michelle Argenbright (540) 848-4123

Inspection Date: March 5, 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

Technical Assistance:

Please send evidence of completed background checks within 10 business days to the licensing inspector.

Comments:

An unannounced monitoring inspection was completed on 03/05/2020 from 8:50 A.M.-1:45 P.M. At the time of the inspection 34 children were in care with four staff and one administrator present. Five children records, six staff records, one medication and required documentation, five over the counter topical ointments and documentation, seven injury reports, emergency plan, first aid kits, emergency supplies, playground, health inspection, fire inspection, asbestos management, and posted required information were reviewed. Children were observed during morning work cycles that included math activities, handwriting, literacy, fine motor activities, quiet reading time, AM snack time, outside play time, handwashing, lunchtime, departure, and naptime. The exceptions to compliance are noted on the violation notice. If you have any questions or concerns contact the licensing inspector at (540)-430-9257 for further assistance.

Violations:

Standard #:	22VAC40-185-60-A
Description:	Based on a review of children files, the center failed to ensure that all required information was in each child's file. Evidence: 1. The date of enrollment was not listed in Child #2, Child #3, and Child #5's file. 2. Child #2's file did not contain complete emergency address for both of the emergency contacts listed. 3. Staff verified that the children files did not contain an enrollment date, and that Child #2's file did not contain emergency addresses for the emergency contacts.
Plan of Correction:	Administration will review all required components with administrative office staff.
Standard #:	22VAC40-185-240-C
Description:	Based on a review of staff training hours, the center failed to ensure that all staff who work directly with children shall annually attend 16 hours of staff development activities. Evidence: 1. Staff #2 had 12.5 hours of training documented for the calendar year October 2018-October 2019. 2. Staff #3 had 8.5 hours of training documented for the calendar year August 2018-August 2019. 3. Administration verified the number of training hours for Staff #2 and Staff #3.
Plan of Correction:	Administration will meet with staff and review the training requirement. Administration will track all training hours and record them accordingly. Staff have been given an update of training hours needed for the current calendar year, and the due date the hours need to be obtained by.
Standard #:	22VAC40-185-260-B
Description:	Based on review of the health inspection, the center failed to ensure that an annual health inspection was conducted. Evidence: 1. The last health inspection on file was dated 11/02/2018. 2. Staff verified that there had not been a health inspection completed since 11/02/2018.
Plan of Correction:	Administration immediately contacted the health department to get an inspection scheduled.
Standard #:	22VAC40-185-510-J
Description:	Based on observation, the center failed to ensure that all medication was kept in a locked location. Evidence: 1. An emergency medication was stored in a medicine box on top of the refrigerator. The medicine box had a padlock attached to the box. The padlock was open and not locked. 2. Staff verified that the medicine box was not locked.
Plan of Correction:	Administration will review with all staff the requirement for all medication to be locked. A staff member checked the medication to see if all required information was on hand, and most likely forgot to lock the box after completing the check. The licensing inspector locked the box after reviewing the medication and required paperwork.
Standard #:	22VAC40-185-550-M
Description:	Based on a review of injury records, the staff failed to ensure that all required information was included in four out of seven injury reports. Evidence: 1. Injury report dated 02/18/2020 did not contain the date the parent was notified, and the method of notification. 2. Injury report dated 01/31/2020, 01/30/2020 and 01/24/2020 did not contain the the date and time the parent was notified, and the method of notification. 3. Administration verified that the reports were missing required information.
Plan of Correction:	Administration will review with all staff the correct way to complete an injury report. When the reports are brought to the office administration will review the reports for completeness before filing.
Standard #:	22VAC40-191-60-C-2
Description:	Based on review of staff files, the center failed to have a completed central registry finding within 30 days of employment. Evidence: 1. Staff #1's file did not contain a completed Central Registry finding. Date of employment for Staff #1 was 09/25/2019. 2. In Staff #1's file there was a copy of the original form that had been placed in the mail and was marked mailed on 09/06/2019. There was not follow up done on the Central Registry finding after not receiving after 30 days. 3. Staff #1 was observed working with a group of children in the downstairs classroom, and counting in ratio. 4. Administration verified that the completed central registry finding could not be located in the file or on her email. Administration also verified that follow-up had not been completed after 30 days of sending out the central registry background check.
Plan of Correction:	Administration will contact the office of background investigation and inquire about the central registry background check. If it can not be located another central registry background check will be sent out. The employee will not work until we have a completed central registry finding.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on review of staff files, the center failed to ensure that a fingerprint based national background check was completed for staff prior to employment. Evidence: 1. Staff #1's file did not contain a completed fingerprint background check. Date of employment was 09/25/2019. 2. Staff #1 was observed working in the downstairs classroom and was counted in ratio. 3. Staff verified that Staff #1's file did not contain a completed fingerprint background check.
Plan of Correction:	Administration could not locate the completed fingerprint background check. Staff #1 will be sent to obtain a fingerprint check, and will not be allowed to work until the results form the background check are obtained.