VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bundle of Joy - Lakeside
6609 Cottage Street
Henrico, VA 23228
(804) 266-8947

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: Feb. 24, 2022

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. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-770 Background Checks (22VAC40-191) 20 Access to minor?s records 22.1 Early Childhood Care and Education 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, and a virtual tour of the program. A monitoring inspection was initiated on 2/23/2022 and concluded on 2/24/2022. The director was contacted by telephone and a virtual inspection was conducted. There were 80 children present, ranging in ages from 2 months to 5 years, with 18 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and background checks. A total of 4 child records and 4 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. 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. Just writing the word ?corrected? is not acceptable. 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 #:	22.1-289.035-B-2
Description:	Based on record review and interview, the center did not ensure to obtain the results of a fingerprint background check for one staff prior to the first date of employment as required. Evidence: 1. The record of staff #2 (DOH: 9/7/2021) contained orientation dated 9/7/2021 and fingerprint background check results dated 9/10/2021. 2. Administration acknowledged that the fingerprint background check results were not received prior the first date of employment.
Plan of Correction:	Center management will make sure all finger prints are received before orientation.
Standard #:	22.1-289.035-B-4
Description:	Based on record review and interview, the center did not ensure to obtain the results of an out of state sex offender registry check prior to the first date of employment and the results of an out of state child abuse and neglect search by the end of the 30th day of employment for 1 staff as required. Evidence: 1. The record of staff #3 (DOH: 11/29/2021) contained a sworn statement that indicated that the staff member had resided outside of the state within the preceding 5 years. 2. The record contained an out of state sex offender registry check dated 12/17/2021. 3. The record did not contain the results of an out of state child abuse and neglect search. 4. Administration acknowledged that the out of state background checks had not been received within the required time frames.
Plan of Correction:	It was attempted to obtain out of state background check multiple times. NC sent multiple letters and different documents each time requiring new documents. We are still waiting results and working with our VA DOE licensing specialist to obtain the correct forms.
Standard #:	8VAC20-770-60-C-2
Description:	Based on record review and interview, the center did not ensure to obtain the results of a central registry background check for each staff within 30 days of employment as required. Evidence: 1. The record of staff #1 (DOH: 10/11/2021) contained central registry background results dated 12/3/2021. 2. The record of staff #2 (DOH: 9/7/2021) contained central registry background results dated 10/20/2021. 3. The record of staff #3 (DOH: 11/29/2021) contained central registry results dated 1/14/2022. 4. Administration acknowledged that the central registry results were not received within the required time frame.
Plan of Correction:	Central registry background checks were completed on first day of employment however were not received back from the state within the required time frame due to backlog in their department. Notes will be taken in the future and placed with the copy of the mailed document as evidence of follow up.
Standard #:	8VAC20-780-70
Description:	Based on record review and interview, the center did not ensure to obtain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering. Evidence: 1. The record of staff # 1 (DOH 10/11/2021) contained orientation dated 10/11/2021 and references dated 10/12/2021. 2. The record of staff #2 (DOH: 09/07/2021) contained orientation dated 9/7/2021 and references dated 10/11/2021 and 10/13/2021. 3. Administration acknowledged that the references were received after hire.
Plan of Correction:	Center management will make sure that all references are completed before employment.