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Community Improvement Council, Inc.
540 Holbrook Street
Danville, VA 24541
(434) 793-5710

Current Inspector: Rebecca Forestier (540) 309-2835

Inspection Date: April 1, 2021

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 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 alternative remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia.

A monitoring inspection was initiated on 03/24/2021 and concluded on 04/01/2021. The provider was contacted by telephone to initiate the inspection. There were 65 children, 24 staff providing direct care/supervision and 18 support staff present during the inspection. The inspector reviewed 4 children's records, 4 staff records and 3 medications during the inspection to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law and violations were documented on the violation notice issued to the facility.

The Licensing Inspector has reviewed with the provider COVID-19 Essential Guidance for Child Care programs.

Violations:
Standard #: 22VAC40-185-160-C
Description: Based on record review and discussion with the staff, the facility failed to obtain the results of a follow-up tuberculosis screening/test at least every two years from the date of the first initial screening/test.

Evidence: The record for Staff #3 contained a tuberculosis screening/test dated 03/10/2019. There was not a follow-up tuberculosis screening/test for 2021 in the record.

Plan of Correction: The program administrator ran a report on upcoming tuberculosis screening/test expirations during the inspection to ensure that any staff with upcoming expirations are notified in time to have a follow-up screening/test completed. Staff #3 will be asked to obtain a follow-up screening/test.

Standard #: 22VAC40-185-260-B
Description: Based on document review and discussion with staff, the facility failed to obtain an annual approval from the health department.

Evidence: The most recent approval from the health department was dated 02/12/2020.

Plan of Correction: The health department was contacted during the inspection. An annual inspection of the facility was requested at that time.

Standard #: 22VAC40-185-510-E
Description: Based on the review of medication and discussion with the staff, the facility failed to ensure that medication shall be labeled with the child's name, the name of the medication, the dosage amount and the time or times to be given.

Evidence: Medication A was not labeled with the child's name, the dosage amount and the time or times to be given.

Plan of Correction: The medication will be returned to the parent.

Standard #: 22VAC40-185-510-N
Description: Based on medication review and discussion with the staff, the facility failed to ensure that when an authorization to administer medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization; medications that are not picked up by the parent within 14 days will be disposed of by the center by either dissolving the medication down the sink or flushing it down the toilet.

Evidence:
1. The medication authorization form for Medication A expired on 12/31/2020; the medication was on-site during the 04/01/2021 inspection.
2. The medication authorization form for Medication B expired on 12/31/2020; the medication was on-site during the 04/01/2021 inspection.

Plan of Correction: The medications will be returned to the parent. The parent will be asked to obtain a new authorization form and/or discuss the need for the medication with the health care provider.

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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