VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Learning Experience
8710 Park Central Drive
Richmond, VA 23227
(804) 264-3054

Current Inspector: Lauren Bickford (540) 280-0742

Inspection Date: Nov. 18, 2021

Complaint Related: No

Areas Reviewed:

8VAC20-780 ADMINISTRATION. 8VAC20-780 STAFF QUALIFICATIONS AND TRAINING. 8VAC20-780 Physical plant. 8VAC20-780 STAFFING AND SUPERVISION. 8VAC20-780 PROGRAMS. 8VAC20-780 Special care provisions and emergencies. 8VAC20-780 SPECIAL SERVICES. 22.1 Early Childhood Care and Education

Technical Assistance:

n/a

Comments:

An unannounced renewal inspection was conducted on Thursday, November 18th, 2021 to determine the center's compliance with licensing standards. The inspector arrived at 1:20pm and concluded the inspection at approximately 5:15pm. The center's director and owner were present and assisted the inspector throughout the inspection. The census for today's inspection consisted of 69 children in the direct care of 10 staff members. Additional staff were on site and available to the children in care. 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 four child records and four staff 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. **During a 90 day implementation period, between 10/13/21-1/13/2022, areas of noncompliance identified with the new standards will not be cited as violations [unless a child is harmed]. These findings will be noted in the comment box on the violation notice. New requirements became effective on October 13, 2021. The facility has not yet fully complied with the following requirement: Tuberculosis screening submitted at the time of employment and prior to coming into contact with children. The facility is to review the new requirements and work with their assigned inspector to ensure future compliance.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on a review of five staff records and interview, the center did not ensure that two out of five staff obtained fingerprint results prior to hire. Evidence: 1) The record for Staff #1, hired on 11/07/21, had fingerprint results that were dated 11/09/21. 2) The record for Staff #2, hired on 11/13/21, had fingerprint results that were dated 11/18/21. 3) During interview, a member of management confirmed the fingerprint results for Staff #1 and Staff #2 were received after their hire date.
Plan of Correction:	Per the Center: "Information regarding fingerprints has been completed and corrected."
Standard #:	22.1-289.035-B-4
Description:	Based on a review of five staff records, the center did not obtain the results of a criminal history record information check, the results of a sex offender registry check, and a search of the child abuse and neglect registry or equivalent registry from any state in which one staff member had resided in the preceding five years within the required time frame. Evidence: 1) The record for Staff #4, hired on 09/08/21, indicated the staff had resided in four states outside of Virginia within the last five years. For two states, the record did not contain a criminal history record information check, a sex offender registry check, or a search of the child abuse and neglect registry. For two states, the record did not contain a sex offender registry check or a search of the child abuse and neglect registry. An out-of-state criminal background check was not required because the states participates in the National Fingerprint File (NFF) program through the FBI. The out-of-state criminal history record information check and the sex offender registry check are required to be obtained prior to hire. The out-of-state search for founded complaints of child abuse or neglect is required to be requested within the first 30 days of being hired. 2) During interview, a member of management confirmed the required out-of-state checks were not obtained for Staff #4 within the required time frames.
Plan of Correction:	Per the Center: "Information was resubmitted to central registry and completed. Information regarding this employee has been received and filed in the staff information file."
Standard #:	8VAC20-770-60-B
Description:	Based on a review of five staff records and interview, the center did not ensure that two out of five staff had a completed sworn statement prior to hire. Evidence: 1) The record for Staff #1, hired on 11/07/21, contained a sworn statement that was dated 11/08/21. 2) The record for Staff #2, hired on 11/13/21, contained a sworn statement that was dated 11/17/21. An employee or volunteer of a licensed or registered child welfare agency or of a family day home approved by a family day system must not be employed or provide volunteer service until the agency or home has the person's completed sworn statement or affirmation.
Plan of Correction:	Per the Center: "Staff records that were missing required information have been corrected and completed."
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of five staff records and interviews, the center did not ensure that one staff member had a central registry finding within 30 days of employment. Evidence: 1) The record for Staff #4, hired on 09/08/21, did not contain the results of a central registry finding. The record did not contain documentation of any further contact, and the staff has been continuously employed.
Plan of Correction:	Per the Center: "Information regarding staff member has been corrected."
Standard #:	8VAC20-780-60-A
Description:	Based on a review of four children's records and interview, the center did not ensure that one child's record contained all the required information. Evidence: 1) The record for Child #1, enrolled on 06/07/21, did not contain the address for the second emergency contact listed. Each child record should contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. 2) During interview, a member of management confirmed the center does not have an address for the second emergency contact listed in the record for Child #1.
Plan of Correction:	Per the Center: "Enrollment information was resubmitted and obtained."
Standard #:	8VAC20-780-70
Description:	Based on a review of five staff records and interviews, the center did not ensure that three staff records contained all the required information. Evidence: 1) The record for Staff #3, hired on 08/30/21, contained documentation that two references were taken over the phone, but the documentation did not indicate the dates of contact and the signature of the person making the call. 2) The record for Staff #4, hired on 09/08/21, contained documentation that two references were taken over the phone, but the documentation did not indicate the dates of contact. Each staff file should contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering. If a reference check is taken over the phone, documentation shall include: dates of contact, name of persons contacted, the firms contacted, the results, and the signature of the person making the call. 3) The tuberculosis (TB) screening results in the record for Staff #5, hired on 09/13/21, were dated 10/27/21. 2) During interview, a member of management acknowledged the TB results for Staff #5 were not obtained within 21 days of beginning employment. Staff hired prior to 10/13/21 were required to obtain TB results within 21 days of beginning employment and such documentation was to be retained in the staff record.
Plan of Correction:	Per the Center: "Missing information from the files have been corrected and filed."
Standard #:	8VAC20-780-270-A
Description:	Based on observations at the center, the center did not ensure that areas of the center were maintained in a clean, safe, and operable condition. Evidence: During the inspection, the licensing inspector observed the following - 1. The inspector observed paint chipping off the walls in the School Age classroom, in the Toddler classroom, and in the Twads classroom. 2. In the Twads classroom, the inspector observed a cabinet door with a broken handle and a protruding nail under the sink by the changing table.
Plan of Correction:	Per the Center: "New cleaning crew has been hired to ensure the cleanliness of the center is being upheld. Painters are set up to start correcting problem areas involving painting. Maintenance has taken care of items such as broken handle and protruding nail."
Standard #:	8VAC20-780-280-B
Description:	Based on observations at the center, the center did not ensure to keep hazardous substances such as cleaning materials in a locked place using a safe locking method that prevents access by children. Evidence: 1) The inspector observed bottles of cleaning supplies in an unlocked cabinet in the Twads classroom.
Plan of Correction:	Per the Center: "All classrooms have been trained on the proper way to store cleaning supplies and have all the proper materials to ensure that all hazardous items are out of reach of children and locked away."
Standard #:	8VAC20-780-510-F
Description:	Based on a review of three medications and interviews, the center did not ensure that one medication authorization was available to staff during the entire time it was effective for one out of three children. Evidence: 1) A prescription medication was observed for Child #5 and no medication authorization was present for this medication. 2) During interview, a member of management reported the authorization for this medication was not present.
Plan of Correction:	Per the Center: "Medication log has been issued in medication binder. All medication is being recorded. Parents were issued new paperwork to fill out along with PCP for their children."
Standard #:	8VAC20-780-540-C
Description:	Based on observation and interviews, the center did not ensure that the required first aid kit included all the required components. Evidence: 1) The first aid kit did not include scissors, tweezers, gauze pads, or adhesive tape. 2) During interview, a member of management reported these items could not be located at the time of the inspection.
Plan of Correction:	Per the Center: "Missing items in first aide kit have been filled."
Standard #:	8VAC20-780-540-E
Description:	Based on observations and interview, the center did not ensure the required nonmedical emergency supplies were at the center. Evidence: 1) During the inspection, a working battery operated flashlight could not be located. 2) During the inspection, a working battery operated radio could not be located. 3) During interview, a member of management reported the items could not be located.
Plan of Correction:	Per the Center: "Non emergency and medical supplies have been purchased for the center."
Standard #:	8VAC20-780-550-D
Description:	Based on a review of documents and interview, the center did not implement a monthly practice evacuation drill for the most likely to occur scenarios. Evidence: 1) The licensing inspector observed the emergency drill log for the year 2021. An evacuation drill was not documented for October 2021. 2) During interview, a member of management reported an evacuation drill was not conducted in October 2021.
Plan of Correction:	Per the Center: "The monthly practice evacuation drill has been implemented and can be found on the information board."