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Country Day School LLC
16241 Woodman Hall Road
Montpelier, VA 23192
(804) 883-6085

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: Sept. 28, 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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor's records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect

Comments:
The licensing inspector conducted an unannounced monitoring inspection on Wednesday, September 28, 2022 from9:45am to approximately 12:00pm. There were a total of 31 children in care in the direct care of six staff members. During the inspection, the children and staff were
observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility including classrooms, kitchen, hallways, playgrounds, and bathrooms were inspected. The required postings were reviewed and found to be in
compliance. Medication is administered when required and medication and medication authorizations were reviewed. The center is equipped with toys and supplies and items were available to the children. During the inspection, five children?s records and five 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 review of five staff records and interview, the center did not obtain a fingerprint-based national criminal background check for one staff prior to employment.

Evidence: 1) The fingerprint-based national criminal background check in the record for Staff #1, employed 08/15/22, was conducted on 02/22/22. 2) During interview, a member of management reported the fingerprints for Staff #1 were received on 02/22/22, but Staff #1 did not begin employment until 08/15/22. Fingerprint-based national criminal background checks are required to be obtained no more than 90 days prior to employment.

Plan of Correction: New fingerprints will be requested. In the future, required background checks will not be accepted if they are dated more than 90 days prior to employment.

Standard #: 8VAC20-770-60-B
Description: Based on a review of five staff records, the center did not ensure that one staff had a completed sworn statement or affirmation within the required time frame.

Evidence: 1) The record for Staff #1, employed 08/15/22, did not contain a completed sworn statement or affirmation prior to the beginning of employment. The sworn statement in the file for Staff #1, dated 02/22/22, was completed more than 90 days prior to employment. Therefore, a new sworn statement should have been obtained prior to employment.

Plan of Correction: A new sworn statement will be completed. In the future, a sworn disclosure dated more than 90 days prior to employment will not be accepted.

Standard #: 8VAC20-770-60-C-2
Description: Based on a review of five staff records, the center did not ensure that central registering findings were obtained within 30 days of beginning employment for one staff.

Evidence: The central registry finding in the record for Staff #1, employed 08/15/22, is dated 02/26/22. A facility must not accept a required criminal history record report or a central registry finding from an applicant, licensee, registrant, or other person required to obtain background checks that is dated more than 90 days prior to the date of employment, volunteering, residing in the home, or approving a family day home or foster or adoptive home. Therefore, a new request for a search of the central registry should have been submitted upon employment, and the results should have been obtained within 30 days of employment.

Plan of Correction: A new central registry will be requested. In the future, a central registry completed more than 90 days prior to employment will not be accepted.

Standard #: 8VAC20-780-160-A
Description: Based on a review of five staff records, the center did not ensure one staff submitted documentation of a negative tuberculosis (TB) screening within the required timeframe.

Evidence: The TB screening in the record for Staff #1, employed 08/15/22, was dated 01/28/22. The documentation should have been completed within the last 30 calendar days of the date of employment.

Plan of Correction: In the future, TB screenings will not be dated more than 30 days prior to the date of employment. The staff will complete a new TB screening.

Standard #: 8VAC20-780-510-F
Description: Based on a review of three medications and interview, the center did not ensure the medication authorization for one medication was available to staff during the entire time it was effective.

Evidence: 1) A prescription medication was observed on site for Child #8, but the medication authorization was not available during the inspection. 2) During interview, a member of management confirmed the medication authorization was not available for review at the time of the inspection.

Plan of Correction: The medication authorization was requested and will be maintained on site during the entire time it is effective.

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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