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Heritage Child Development Center
224 Mosby Blvd.
Berryville, VA 22611
(540) 955-4194

Current Inspector: Barbara Workman (540) 430-9257

Inspection Date: Feb. 3, 2021

Complaint Related: Yes

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-191 Background Checks (22VAC40-191)
63.2(17) License & Registration Procedures

Comments:
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by Governor of Virginia.

A complaint investigation was conducted on February 3, 2021. A complaint was received by the department on January 18, 2021 regarding allegations in the areas of record keeping, accident/injury reports, supervision, and COVID-19 protocols. The director was contacted by telephone to conduct the investigation. The inspector emailed the director a list of documentation required to complete the investigation. Seven children record's, four staff record's, accident/injury reports for the month of December/January were reviewed. Interviews and classroom observations were conducted.

The evidence gathered during the investigation supported the allegation of non-compliance with standards or law and violations were issued and documented on the violations notice issued to the facility.

If you have any questions or concerns you can contact the Licensing Inspector at 540-430-9257.

Violations:
Standard #: 22VAC40-185-60-A
Complaint related: Yes
Description: Based on review of children records, the center failed to ensure all required documentation was in the record.

Evidence:
1. Child #2's file did not contain updated immunizations required every six months for children under the age of two. Date of birth for Child #2 is 03/21/2019. Date or enrollment for Child #2 was 05/13/2019. Immunizations on file were dated 05/19/2019, 05/30/2019, 05/11/2020, and 10/01/2020. Immunizations were not obtained in November of 2019.
2. Child #2's record did not contain documentation of an annual update of emergency contact information. Child #2's last documented annual review is dated 04/19/2019. Date of enrollment for Child #2 was 05/13/2019.
3. Child #6's record did not contain documentation of an annual update of emergency contact information. Child #6's last documented annual review is dated 01/19/2019. Date of enrollment for Child #6 was 01/10/2019.
4. Child #7's record did not contain documentation of an annual update of emergency contact information. Child #7's last documented annual review is dated 07/31/2019. Date of enrollment for Child #7 was 08/05/2019.
5. Immunizations for Child #7 were obtained late. Date of enrollment for Child #7 was 08/05/2019. Immunizations were dated 03/06/2020.
6. Proof of birth was not obtained for Child #7, date of enrollment was 08/05/2019. Verification of birth was documented as viewed on 11/20/2019.

Plan of Correction: A child file spreadsheet will be used to ensure all required documentation is up to date, and meets the timeframe requirements for enrollment. The spreadsheet will include dates of initial physical record and immunizations, along with a space for dates updated records are needed per licensing regulations specific to the the child's age to be entered. We will also utilize our school data software which will initiate reminders as the families need to provide updated records. Our child file checklist will include details regarding enrollment requirements and timeline on when items need to be returned.

Standard #: 22VAC40-185-550-L
Complaint related: Yes
Description: Based on review of accident/injury reports, the center failed to ensure that parents were notified by the end of a day for a minor injury.

Evidence:
1. On an injury report dated 12/08/2020 from the toddler classroom the parent did not sign the report and was not notified until 12/09/2020.
2. On an injury report dated 12/21/20 from the infant classroom the parent did not sign the report and was not notified until 12/23/2020.
3. Staff verified the dates of the injury and injury reports and the dates the parents were notified.

Plan of Correction: All parents/guardians will be notified the day of accident/injury and will be documented on the accident report. All staff members are to notify administration immediately after an accident or injury occurs to ensure parent/guardians are notified.

Standard #: 22VAC40-185-550-M
Complaint related: Yes
Description: Based on review of accident/injury reports, the center failed to ensure that all required information was contained on the report.

Evidence:
1. Accident/Injury reports dated 12/4/2020, 12/10/2020, and 12/15/2020 did not contain further action to prevent reoccurrence.
2. Accident/Injury reports dated 12/3/2020,1 12/4/2020, 12/8/2020, 12/14/2020, and 01/19/2021 did not contain the time the parents were notified.
3. Accident/Injury report dated 01/19/2021 did not contain the method the parent was notified.
4. Staff verified that accident reports were missing further action to prevent reoccurrence, method of notification, and time parents were notified of the accident/injury.

Plan of Correction: All staff member will receive an initial and refresher training on how to write accident reports to ensure all required information is being documented. The Director will continue to work with staff members who are in need of additional training. All accident reports will be reviewed by the Director or Assistant Director on the spot training will occur with staff when needed.

Standard #: 22VAC40-191-60-C-2
Complaint related: No
Description: Based on review of staff records, the center failed to ensure that a central registry background check has been obtained within 30 days of employment.

1. Staff #3's file did not contain a completed Virginia central registry background check. Date of employment for Staff #3 was 11/30/2020.
2. Administration verified that there was not a completed Virginia central registry background check in Staff #3's record.
4. Administration verified that a follow up with the Office of Background Investigation had not been completed by the end of the 30th day of employment to check on the status of the background check.

Plan of Correction: A staff file spreadsheet will be used to track Central Registry Background Checks, the date that the background check was mailed will be noted in the spreadsheet along with the date the background check was completed and received by administration. If the background check has not been received by the end of the 30th day, a follow up email will be sent to the Office of Background Investigation. The center will provide the Licensing Inspector with evidence that this process has been started/or completed within 10 business days.

Standard #: 63.2(17)-1720.1-B-3
Complaint related: No
Description: Based on a review of new staff background checks, it was determined that one staff member required an out of state central registry background search that was not completed.

Evidence:
1. Staff #3 began employment on 11/30/2020. Staff #3 indicated that she resided in one state other than Virginia within the past 5 years on her Sworn Disclosure Statement dated 11/30/2020. The required out of state central registry search request for this staff person has not been submitted.
2. Staff verified that the record check had not been submitted within the required time frame.

Plan of Correction: A staff file spreadsheet will be used to track out of state background checks to ensure all staff member who have lived outside of the Virginia within the past 5 years has an out of state central registry background check completed. The center will provide the Licening Inspector with proof that this background checks has been started/or completed within 10 business days.

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. To find programs participating in Virginia Quality, click here.

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