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Braddock Street United Methodist Church
103 South Braddock Street
Winchester, VA 22601
(540) 667-8915

Current Inspector: Stephanie Reed (540) 272-6558

Inspection Date: March 28, 2022

Complaint Related: No

Areas Reviewed:
8VAC20-780 Administration
8VAC20-780 Staff Qualifications & Training
8VAC20-780 Physical Plant
8VAC20-780 Staff & Supervision
8VAC20-780 Programs
8VAC20-780 Special Care, Provisions & Emergencies
8VAC20-780 Special Services
8VAC20-770 Background Checks (22VAC-40-191)
22.1 Early Childhood Education & Care

Comments:
This inspection was conducted by licensing staff using a hybrid inspection protocol, including telephone contacts, documents review, interviews, and an on-site inspection was completed.

A renewal inspection was initiated on March 28, 2022 and concluded on March 30, 2022. The director was contacted by telephone and sent requested documentation. An onsite inspection was completed on March 30, 2022 from 11:00 a.m.-3:00 p.m. There were 62 children present, ranging in ages from four months to five years of age, 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 nutrition. A total of five child records and 12 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.

If you have any questions or concerns please contact the Licensing Inspector at 540-430-9257.

Violations:
Standard #: 8VAC20-780-160-A-1
Description: Based on review of staff records, the center failed to ensure that documentation of a tuberculosis screening was obtained prior to staff coming into contact with children.

Evidence:
1. Staff #1's tuberculosis test/screening was dated 03/09/2022. First day of employment and being in contact with children was 03/04/2022.
2. Staff #2's tuberculosis test/screening was dated 03/28/2022. First day of employment and being in contact with children was 03/11/2022.

Plan of Correction: Any new hires will have to have the tuberculosis screening or test before beginning employment.

Standard #: 8VAC20-780-160-A-2
Description: Based on review of staff records, the center failed to ensure that tuberculosis screeting/test was within 30 days of employment.

Evidence:
1. Staff #3's date of employment was 03/02/2022. The tuberculosis screening/test on file was dated 08/16/2021.
2. Staff verified the date of employment for Staff #3 and the date on the tuberculosis screening/test.

Plan of Correction: Administration was unaware of the change in the standards. In the future any new employee's tuberculosis screening will be reviewed to make sure it is within the required timeframes, or be requested to obtain a new tuberculosis screening.

Standard #: 8VAC20-780-70
Description: Based on a review of staff records, the center failed to obtain two reference checks before a staff member's first day of employment.

Evidence:
1. Staff #12's date of employment was 07/14/2021. One reference check for Staff #12 was dated 08/02/2021.
2. Staff verified the date of employment for Staff #12, and the date documented on the reference check.

Plan of Correction: In the future administration will use a two tier audit system to ensure all required paperwork is on file before the first day of employment.

Standard #: 8VAC20-780-520-A
Description: Based on a review of medications and interview, the center failed to ensure that all non-prescription drugs were used in accordance with the manufacturer's recommendations.

Evidence:
1. On 03/28/2022 Child 7M was administered 3.75ml of a non-prescription medication. The directions on the medication stated if under 24 pounds or under the age of 2 to contact a doctor.
2. The medication authorization form was not completed by the physician, and did not have the correct dosage amount for Child 7M.

Plan of Correction: Administration will contact the parent and request the medication authorization form be completed by a physician if they wish to keep the medication at the center. In the future all non-prescription medication will be checked against the manufacturer's direction to ensure the medication can be given with out a physician authorization.

Standard #: 8VAC20-780-560-G
Description: Based on observation and interview, the center failed to ensure that all food brought in from home was labeled with the child's name and date.

Evidence:
1. In Classroom #1 there were three lunchboxes that did not contain the child's name or date.
2. In Classroom #2 there were 11 lunch bags in the refrigerator. The lunch bags were not marked with the date.

Plan of Correction: Administration will retrain staff on the requirements for food brought in for home. Administration will do spot checks to ensure all food brought in from home is labeled with the child's name and date.

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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