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Children of America Salem Church, LLC
12008 Old Salem Church Rd
Fredericksburg, VA 22407
(540) 548-1555

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: Aug. 18, 2021 , Aug. 25, 2021 , Aug. 30, 2021 and Sept. 17, 2021

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.

Comments:
This inspection was conducted by licensing staff using a combination of an alternate remote protocol including telephone contacts, documents review, and interviews with staff and in-person observations.

An unannounced monitoring inspection was conducted to investigate a self report received by The Department related to the Physical Plant and Staffing and Supervision at the center. The inspection was initiated on 8/18/2021 and concluded on 9/17/2021 with an exit interview. The evidence gathered during the inspection supported the allegations of non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.

Please complete the columns for "Plan of Correction" and "Date to be Corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office by 4:00pm on Friday, 9/24/2021. If you have further questions about this inspection please contact Donna Liberman at 540-359-5244 or Donna.Liberman@doe.virginia.gov.

Violations:
Standard #: 22VAC40-185-40-K
Description: Based on staff interviews, and documentation review, the center failed to have written playground safety procedures which include provision for active supervision by staff to include positioning of staff in strategic locations, scanning play activities, and circulating among children. Evidence: there was no documentation of written playground safety procedures that included provision for active supervision.

Plan of Correction: All staff will have continued training through CCEI for the next 3 months on: playground safety procedures and supervision of children outdoors.
All staff will be doing ongoing training in active supervision.

Standard #: 22VAC40-185-240-A
Description: Based on review of documentation, not all staff received orientation training by the end of their first day of assuming job responsibilities. Evidence: the record for staff #2, date of hire: 6/21/2021, had documentation of orientation dated: 6/23/2021.

Plan of Correction: Director will ensure all documents are signed the day of completion of orientation.

Standard #: 22VAC40-185-270-A
Description: Based on observation, review of photographs, and interviews with staff, not all areas of the center outside the facility were maintained in a safe and operable condition. Evidence: 1) The fence surrounding the playground had warped and leaning boards, loose, missing and protruding nails, cracked, splintering and deteriorating wood, and rotting at the base of the boards; 2) There were three missing vertical boards (pickets), two on the outside of the playground fence and one on the inside of the fence; 3) There was a loose picket located outside of the fence, opposite one of the missing inside pickets, that came off of the fence while children were playing on the playground, leaving a gap in the fence approximately ten inches wide by two-three feet tall.

Plan of Correction: A New permanent primary fence has been ordered due to shortages of materials installation has been delayed. (180 days)
Children of America maintenance team will be installing an additional barrier to reinforce the current fence. (10/31/21)
Children of America maintenance team will do weekly inspections of the fence until new fence is installed.
Managers of Children of America Salem Church will be inspecting fence daily on a schedule of Opening, Mid-day and Closing.
Any potential concerns will be reported to the maintenance team.
Playground will be closed until corrected.

Standard #: 22VAC40-185-340-A
Description: Based on staff interviews, and documentation review, the center failed to ensure the care, protection, and guidance of children on the playground. Evidence: On August 17, 2021 at approximately 3:50 pm, Child #1, age three, climbed through a hole in the playground fence that was approximately ten inches wide by two-three feet tall. Staff interviews revealed that there was no hole of that size in the fence when the class arrived on the playground at approximately 3:45 pm, though several smaller holes were observed. Staff #2 stated they did not see the child go through the fence because they were playing tag with the children. Staff #1 stated they did not see the child go through the fence as they were engaged in conversations with parents regarding mask mandates, filling out an incident report, and signing children out on the online attendance platform. Child #1 was retrieved by a bystander at approximately 3:55 pm, near a road behind the facility, and brought back to office staff at the center.

Plan of Correction: All staff have been trained in risk management on the playground to include a visual inspection upon entering the playground for potential risks.

Standard #: 22VAC40-185-340-F
Description: Based on staff interviews, and documentation review, the center failed to ensure that all children under ten years of age were within actual sight and sound supervision of staff at all times. Evidence: On August 17, 2021 at approximately 3:50 pm, Child #1, three years of age, climbed through a hole in the fence and wandered outside the playground towards a road behind the facility. Staff #1 stated they first observed Child #1 outside the playground area standing approximately two to three feet away from the fence. Staff #1 stated they went up to the fence and called to the child through the fence, but then looked down to prevent other children from climbing through the hole. When staff #1 looked up again they could not see Child #1 anywhere in the vicinity. Staff # 1 stated that they ran through several gates, out of the playground, and around the back of the facility but could not locate Child #1. Child #1 was out of staff sight and sound supervision for approximately 5 minutes.

Plan of Correction: All staff will be doing ongoing training in sight and sound supervision to include active supervision. (8/31/21, ongoing)
All staff will be receiving emergency preparedness action plan training to include roles of each staff during an emergency situation. (10/15/21)
All staff will engage in monthly drills on emergency action plan. (ongoing)

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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