VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Learning at the Lake, LLC
16050 Mountain Road
Montpelier, VA 23192
(804) 363-9124

Current Inspector: Heather Dapper (804) 625-2304

Inspection Date: Sept. 7, 2021 and Sept. 8, 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 (22VAC40-191) 20 Access to minor?s records 32.1 Report by person other than physician 63.2 Child Abuse & Neglect 63.2(17) License & Registration Procedures 63.2 Facilities & Programs.

Technical Assistance:

The licensing inspector reviewed the new Carbon Monoxide Detector requirement (? 22.1-289.058) with the provider.

Comments:

An announced initial inspection was conducted on September 7, 2021 from 10:00am to 1:30pm and a virtual record review was conducted on September 8, 2021. There were no children in care during this inspection as the center has not yet opened for child day care purposes. The center consists of three classrooms, three bathrooms, an office, kitchen, and storage closet. The center is requesting a license for children ages newborn through 12 years. The program will offer morning snack and afternoon snack to children in care. Medication will not be administered. Transportation will not be provided. The center has submitted all of the required application materials at this time. During the inspection, compliance with some standards could not be determined since the center is not yet in operation. Compliance with these standards will be determined during unannounced visits once the program is in operation. Though some standards of care could not be determined during the initial study, the center is in substantial compliance with the standards that could be determined. A six-month conditional license will be recommended. During the conditional period, the center will be subject to unannounced licensing inspections, with the first inspection taking place within the first sixty days of licensure. If you have any questions about this inspection, please contact your licensing inspector, Kandra Brown, at (804) 929-3771. Please complete the plan of correction, and date to be corrected for each violation listed on the violation notice and return it to me within 5 business days from receipt. Your plan of correction should 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 #:	22VAC40-185-240-D-5
Description:	Based on record review, the center did not ensure that there was at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children. Evidence: 1. Two staff records were reviewed and neither staff record contained documentation of daily health observation training. 2. The center representative stated that they did not have the required training but will take the training as soon as possible.
Plan of Correction:	Daily health observation cert. has been received.
Standard #:	22VAC40-185-500-B
Description:	Based on observation, the center did not ensure that the diapering surface was a nonabsorbent. Evidence: The diaper pad had several tears in the material causing absorbent areas to be exposed.
Plan of Correction:	Diaper pad replaced.
Standard #:	22VAC40-185-530-A
Description:	Based on record review, the center did not ensure at least one staff member was trained in first aid, cardiopulmonary resuscitation, and rescue breathing as appropriate to the age of the children served. Evidence: 1. Two staff records were reviewed and the records did not have documentation of current first aid and CPR certification. 2. The record of staff #1 had documentation of a first aid and CPR certification which expired 1/2021. 3. The record of staff #2 had documentation of a first aid and CPR certification which expired 1/2021.
Plan of Correction:	CPR training received for both employees.
Standard #:	22VAC40-185-550-A
Description:	Based on record review, the center did not ensure the emergency preparedness plan was developed in consultation with local or state authorities. Evidence: The center's emergency preparedness plan was not developed in consultation with a local or state official. The center representative stated that they have requested that their emergency plan be reviewed by a local fire official and they are currently waiting on a response.
Plan of Correction:	I talked with the local Deputy Emergency Coordinator and he will review the emergency plan by Monday 9/15/21.
Standard #:	22VAC40-185-550-B
Description:	Based on record review, the center did not ensure that the emergency plan addressed most likely to occur emergency scenarios and contained all of the required procedural components. Evidence: 1. The center's emergency plan did not address how the center will respond to a natural disaster, chemical spill and terrorism. 2. The center's emergency plan did not contain the required procedural components, such as: sounding alarms; identification of and phone number for the center's primary and secondary emergency officer; notification of poison control, health department and local media; availability and primary use of communication tools; and how often the plan will be reviewed and updated. 3. The evacuation plan did not include head counts, complete evacuation from the building, a plan to secure documents, and special health care supplies to be carried off site. 4. The shelter in place did not include head counts, a plan to secure essential documents, and special health supplies to be carried to designated assembly points.
Plan of Correction:	I have revised the emergency plan and added all required procedures. The plan is currently under review by the Deputy Emergency Coordinator.