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Bon Secours Family Center @ SMH
1403 Maple Avenue
Richmond, VA 23226
(804) 285-0444

Current Inspector: LaTasha Smith (804) 588-2362

Inspection Date: July 16, 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 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS
22VAC40-191 Background Checks

Comments:
This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, interviews and a virtual tour of the program.

A renewal inspection was initiated on July 16, 2021 and concluded on July 19, 2021. The director was contacted by telephone and a virtual inspection was conducted. There were 45 children present with 11 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 3 child records, 4 staff records, and 4 officers of the board records were reviewed.

Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.

Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations:
Standard #: 22VAC40-191-40-D-1-A
Description: Based on a review of records and interview on July 19, 2021, the center did not ensure to obtain a Sworn Statement for each new officer when a change occurred and a central registry check from each Officer of the Board before the end of the 30 days after the change of officer.
Evidence: 1. The record of Officer #1 (Date of Office 1/1/21) contained documentation of a sworn statement dated 4/30/21 and central registry results dated 5/7/21).
2. The record of Officer #2 (Date of Office 1/1/20) contained documentation of a sworn statement dated 2/20/20 and central registry results dated 3/26/20.
3. The record of Officer #3 (Date of Office 1/1/21) contained documentation of a sworn statement dated 4/23/21 and central registry results dated 5/7/21.
4. Administration acknowledged the background checks were not completed within the timeframe.

Plan of Correction: Monthly check-ins with the Board's Administrative support to ensure we are aware of upcoming changes ahead of time. The Board of Directors has no oversight of the childcare centers and does not come to our facilities. With some changes in administrative support and unexpected changes due to the pandemic we learned of these transitions after they had occurred. At that point we initiated the required screenings.

Standard #: 63.2(17)-1720.1-B-4
Description: Based on a review of records and interview on July 19, 2021, the center did not obtain results of a check of the out-of-state criminal history and sex offender registry prior to employment for each employee and did not request an out-of-state search of the child abuse and neglect registry or equivalent by the end of the 30th day of employment for each employee who has resided in any other state in the preceding five years.
Evidence: 1. Officer #3 indicated on the sworn disclosure statement living in two states outside of Virginia within the past five years. The record of Officer #3 (Date of Office 1/1/21) contained documentation of out-of-state sex offender registries dated 5/5/21 and 5/18/21, criminal history check dated 5/28/21, and central registry checks dated 5/18/21 and 6/9/21.
2. Administration acknowledged the background checks were not completed timely.

Plan of Correction: Monthly check-ins with the Board's Administrative support to ensure we are aware of upcoming changes ahead of time. The Board of Directors has no oversight of the childcare centers and does not come to our facilities. With some changes in administrative support and unexpected changes due to the pandemic we learned of these transitions after they had occurred. At that point we initiated the required screenings.

Standard #: 63.2(17)-1721.1-B-2
Description: Based on a review of records and interview on July 19, 2021, the center did not ensure to obtain a fingerprint based national criminal record check within 30 days of appointment of a board officer.
Evidence: 1. The record of Officer #1 (Date of Office 1/1/21) contained documentation of fingerprints dated 5/5/21.
2. The record of Officer #2 (Date of Office 1/1/20) contained documentation of fingerprints dated 3/3/20.
3. The record of Officer #3 (Date of Office 1/1/21) contained documentation of fingerprints dated 5/17/21.
4. Administration acknowledged the background checks were not completed within the timeline.

Plan of Correction: Monthly check-ins with the Board's Administrative support to ensure we are aware of upcoming changes ahead of time. The Board of Directors has no oversight of the childcare centers and does not come to our facilities. With some changes in administrative support and unexpected changes due to the pandemic we learned of these transitions after they had occurred. At that point we initiated the required screenings.

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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