VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Kids Come 1st Inc
1605 South Church Street
Smithfield, VA 23430
(757) 357-2006

Current Inspector: Melinda Popkin (757) 802-5281

Inspection Date: Aug. 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. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

Today we discussed the importance of being able to "demonstrate" compliance with the standards. Documentation must be available to demonstrate emergency drills conducted (shelter in place and lockdown drills for previous years if you have not yet conducted them for the current year) and Documentation that your Liability Insurance is current / active. Not only do you have to have a policy in place that items are labeled before they come in the center - staff must check items as children arrive and label them if parents have failed to do so. Demonstrated compliance is when the items are checked and have appropriate labels. Resilient surfacing under and around outdoor play equipment can be maintained over a longer period of time if grass and weeds are pulled as they come up and if the mulch is frequently raked and fluffed and spread into areas where it it gets pushed away as children utilize equipment (swings). As the material becomes compacted, it loses its resiliency and when it is pushed away from fall zones it no longer serves the purpose of cushioning a child's fall from equipment. A brochure outlining safe sleep practices for infants was shared with the licensee. The timing of the following items required for staff in licensed CDCs was discussed: Finger Prints / Criminal History Record Check - PRIOR to HIRE (results before an employment offer, training or orientation etc.) Sworn Statement or Affirmation - Signed prior to employment / working Search of the Central Registry - requested within 10 days of employment and results back within 30 days of employ Tuberculosis Screening - Negative Results PRIOR to contact with children Center Orientation - Before working alone with children and no later than 7 days after employed VDOE Orientation (Virginia Preservice Training) - within 90 calendar days of employment

Comments:

A monitoring inspection was initiated and concluded on 8/24/2022. At the time of the inspector's arrival there were 80 children present, ranging in ages from 6 months to 9 years old, with 11 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 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.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on record review and interview, the licensee was unable to demonstrate that each staff submits to fingerprinting for the purpose of a Federal Criminal History Record Check prior to being employed by the program. Evidence: Four staff records were reviewed. The record for staff #3, who is employed as a teacher's assistant, and the record for staff #4 whose date of hire was documented as 8/22/2022, did not contain documentation of a Criminal History Record check which is required prior to employment. The staff in charge at the time of inspection confirmed that this documentation was not available.
Plan of Correction:	The licensee will submit a plan of correction within 5 days of this notice which is dated 9/8/2022.
Standard #:	8VAC20-770-60-B
Description:	Based on record review and interview, the licensee was unable to demonstrate that each staff member completes a sworn statement or affirmation prior to working in the program. Evidence: Four staff records were reviewed. The record for staff #3, who is currently employed as a teacher's assistant at the center, did not contain a signed sworn statement or affirmation. The staff member in charge at the time of inspection confirmed that this documentation was not available at the time of inspection.
Plan of Correction:	The following written response was submitted to the department on 9/12/2022: "was signed on 8/24/22. Original one had been misplaced."
Standard #:	8VAC20-770-60-C-2
Description:	Based on record review and interview, the licensee was unable to demonstrate that a search of the central registry is conducted for every staff within 30 days of employment. Evidence: Four staff records were reviewed. The record for staff #3, who is employed as a teacher's assistant, did not contain documentation of a Search of the Central Registry. Staff #3 was working with children in the school age classroom during the inspection. The staff member in charge at the time of inspection confirmed that this documentation was not available at the time of inspection.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "This was an overlook central registry was mailed off 8/24/2022"
Standard #:	8VAC20-780-160-A
Description:	Based on a review of records and interview, the licensee did nor ensure that each staff member submits documentation of a negative Tuberculosis screening. Evidence: Four staff records were reviewed. The records for staff #3 and the record for staff #4 who are currently employed as teacher's assistants, did not contain the results of a Tuberculosis screening. The staff member in charge confirmed that staff #3 and staff #4 have been in contact with the children and that documentation of a tuberculosis screening was not available.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "Both staff are scheduled to get TB results"
Standard #:	8VAC20-780-40-H
Description:	Based on a review of documentation and interview, the licensee was unable to demonstrate that they maintain public liability insurance for bodily injury for the center with a minimum limit of at least $500,000 each occurrence and with a minimum limit of $500,000 aggregate. Evidence: The most recent liability insurance document that was available for review was dated 7/26/2021 through 7/26/2022. When asked if a current policy was in place, the individual in charge stated that the director called the insurance agent last week and that they are in the process of renewing the policy.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "Insurance was in renewal, forms are being sent to me by 9/12/22 from JCS Insurance"
Standard #:	8VAC20-780-60-A
Description:	Based on a review of records and interview, the licensee was not able to demonstrate that a separate record for each child enrolled, containing all of the required information, was maintained. Evidence: Four enrolled children's records were reviewed. The record for child #4 did not contain an address for the either of the 2 individuals to be contacted in an emergency if the parents are not able to be reached. The record for child #2 did not contain the 3 required agreements signed by the parent regarding authorization for medical care, ill child parent notification and pick up, and disclosure if the child or household member develops any reportable communicable disease. The staff person in charge was unable to produce this documentation during the inspection.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "Children's folders have been fixed as of 9/9/22"
Standard #:	8VAC20-780-70
Description:	Based on record review and interview, the licensee did not maintain a record for each staff member which contains all required documentation. Evidence: Four staff records were reviewed. The record for staff #3 did not contain a date of employment. The records for staff #3 and staff #4 did not contain documentation that 2 references as to character, reputation and competency were checked. The records for staff #3 and staff #4 did not contain documentation to demonstrate that they posses the education, certifications, experience, orientation and training required of their position. The individual in charge at the time of the inspection confirmed that she was unable to locate this documentation during the inspection.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "References were called and made on 8/24/22"
Standard #:	8VAC20-780-240-B
Description:	Based on record review and interview, the licensee was unable to demonstrate that each staff completes a Program Specific orientation prior to working alone with children and no later than 7 days after assuming job responsibilities. Evidence: The record for staff #3 who is employed as a teacher's assistant, did not contain documentation that the employee was oriented to program specific information. Staff #3 was working in the school age classroom during the inspection. The staff member in charge at the time of inspection confirmed that this documentation was not available at the time of inspection.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "Staff had signed on 8/24/22"
Standard #:	8VAC20-780-270-A
Description:	Based on observation and interview, the licensee did not ensure that all areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition. Evidence: The inspector observed that the fence surrounding the outdoor play area was in disrepair resulting in unsafe conditions to include areas which could result in head entrapment, as well as deteriorating wood, and protruding nails that could entangle clothing or snag skin. There were 2 single wood planks missing from one fence panel in two places, leaving 2 open gaps of about 4" and one fence panel missing double (two) planks, leaving an open gap of about 8". There was an entire 8 foot fence panel which had come untethered from the support post and which was leaning into the play yard resulting in an opening in the fence ranging in size from a few inches at the bottom of the panel and increasing to to a gap of approximately 2 feet at the upper portion of the panel. There were 5 exposed nails along the opening of the collapsed panel with the pointed / sharp end of the nail protruding outward from the fence support toward the play yard. There were 12 four year old children with one staff on the outdoor play space at the time of this observation. The staff in charge during the inspection acknowledged the disrepair of the fence at the time of the inspection.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "Fence was fixed on 9/3/22. All loose boards have been fixed."
Standard #:	8VAC20-780-280-B
Description:	Based on observation and interview, the licensee did not ensure that hazardous substances such as cleaning materials, insecticides, and pesticides are kept in a locked place using a safe locking method that prevents access by children. Evidence: The licensing inspector observed multiple cleaning materials with warning labels to include a statement to "Keep out of reach of children" and containing additional warnings to include "contact poison control" or a "contact a physician if swallowed", or identifying the contents as flammable or combustible. These items were located in an unsecured bottom cabinet in the kitchen which is open to the school aged classroom where 18 children were present. The accessible cleaning products included: 6 aerosol cans of Disinfectant spray; 3 spray bottles of scented air freshener; 1 bottle of isopropyl alcohol and 1 bottle of concentrated floor cleaner. The staff person in charge during the inspection acknowledged that these items were accessible to children and relocated them when she they were brought to her attention by the inspector.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "All products were moved into the storage closet during inspection. All staff have been informed that extra cleaning supplies go into locked storage closet, not kitchen cabinets."
Standard #:	8VAC20-780-330-B
Description:	Based on observation, the licensee did not ensure that, where playground equipment is provided, resilient surfacing complies with minimum safety standards to include a minimum of 6 inches of resilient surfacing under and around equipment used for climbing or with moving parts. Evidence: The areas under and around the set of 6 swings contained wooden mulch which was compacted and covered in crab grass and weeds and was no longer loose and resilient. Under each swing bay, the ground was concave where children's feet sweep the ground and bare compacted dirt was observed under these areas.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "New mulch will be delivered 9/14/22. Children are staying off swings until delivered".
Standard #:	8VAC20-780-350-B-1
Description:	Based on observation and interview, the licensee did not ensure that the required ratio of 1 staff per 4 children was maintained for children birth up to 16 months old. Evidence: The inspector observed 9 infants, ages 6 months to 1 year old with 2 staff at the time of the inspection. The staff in charge during the inspection acknowledged the number of staff and children in the infant room and said that the third staff in this classroom had a doctor's appointment and would return following completion of her appointment.
Plan of Correction:	The following written response was received by the department on 9/12/2022: " Center has already addressed that ratio increase is not longer in effect. All staff have been informed and new hires have been made."
Standard #:	8VAC20-780-350-B-2
Description:	Based on observation and interview, the licensee did not ensure that the required ratio of 1 staff per 5 children was maintained for children ages 16 months old up to 24 months old. Evidence: The inspector observed 11 toddlers, ages 16 months to 2 years old with 2 staff at the time of the inspection. The staff in charge during the inspection acknowledged the number of staff and children in the toddler room and said that they had two staff call out sick on this day and did not have another staff to assist in this classroom.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "Program Director has hired a sub to fill in when employees call out."
Standard #:	8VAC20-780-350-B-4
Description:	Based on observation and interview, the licensee did not ensure that the required ratio of 1 staff per 10 children was maintained for children ages 3 through 4 years old. Evidence: The inspector observed twelve four year old children with 1 staff at the time of the inspection. The staff in charge during the inspection acknowledged the number of staff and children in the four year old classroom and said that they had two staff call out sick on this day and did not have another staff to assist in this classroom.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "Center was under the impression that the temporary staff to ratio increase due to staffing shortages was still in effect. It expired 6/22. All staff have been informed 8/24/22."
Standard #:	8VAC20-780-550-G
Description:	Based on observation and interview, the licensee was unable to demonstrate that the program maintains documentation of shelter in place and Lockdown drills. Evidence: The emergency drill log was reviewed by the inspector. The log contained documentation of monthly evacuation drills conducted. When asked if the center conducted shelter-in-place drills or lockdown drills, the staff in charge stated that she thought so, but she was unable to produce any documentation to demonstrate that these drills had been practiced.
Plan of Correction:	The following written response was received by the department on 9/12/2022: "Program director had given the inspector the emergency book that had last shelter in place drill on 5/17/22 (was lock down drill) overlook of both inspector and new program director."