VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Culpeper Human Services - Kid Central Farmington
500 Sunset Lane
Culpeper, VA 22701
(540) 829-2124

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: Nov. 1, 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 (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced monitoring inspection was conducted on-site November 1, 2022 and concluded remotely on November 3, 2022. The director was available during the inspection. There were 37 children present, ranging in ages from 5 years to 12 years, with 3 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 5 child records and 3 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. Please specify how the deficient practice will be or has been corrected. Your plan of correction should 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 #:	8VAC20-770-60-C-2
Description:	Based on a review of staff records and interview on November 1, 2022, the center failed to ensure that each staff record reviewed contained a central registry finding within 30 days of employment. Evidence: 1. The record of staff #2, hired 11/11/21, contained documentation of central registry results dated 12/29/21. Administrator #1 confirmed the results were late.
Plan of Correction:	Background checks need to be sent off upon hire or within 7 days of hire date. If report is not received by day 30, follow up with the central registry is required and must be documented. Any staff whose background check is not received within 30 days, will not be able to work until follow up ensures the staff member is eligible. The program will meet this requirement by using an electronic tracker that shows when the background checks are sent off and due to be returned. This will be monitored and maintained by the Program Manager.
Standard #:	8VAC20-780-130-A
Description:	Based on a review of children?s records on November 1, 2022, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: 1. The record of child #1, enrolled 7/13/22, contained documentation of immunizations dated 10/31/22. 2. The record of child #4, enrolled 8/9/22, contained documentation of immunizations dated 9/27/22.
Plan of Correction:	The program will meet this requirement by making sure The Enrollment Coordinator uses the standards to make sure we have all mandated information before enrolling a child into the program and will assure there is a signature or stamp from the doctor?s office on each physical and immunization record before the child is allowed to attend. The immunizations must be received before the child can start with the program. This is the responsibility of the Enrollment Coordinator and will be monitored at each site by the Team Leader.
Standard #:	8VAC20-780-240-A
Description:	Based on a review of staff records, the center failed to ensure that staff complete the Virginia Department of Education sponsored orientation course within 90 calendar days of employment. Evidence: 1. The record of staff #2, hired 11/11/21, contained documentation of the Virginia Department of Education sponsored orientation dated 8/15/22.
Plan of Correction:	Staff members are required to have orientation training within 90 days of hire. The program will meet this requirement by using an electronic tracker that shows when orientation was completed for the new hire. It is the responsibility of the program manager to ensure this requirement is met.
Standard #:	8VAC20-780-240-A
Description:	Based on a review of staff records, the center failed to ensure that staff complete the Virginia Department of Education sponsored orientation course within 90 calendar days of employment. Evidence: 1. The record of staff #2, hired 11/11/21, contained documentation of the Virginia Department of Education sponsored orientation dated 8/15/22.
Plan of Correction:	Staff member was originally hired by partner on 11/11/21. Kid central acquired and conducted orientation on 2/17/22 for the staff member when she started working for us. It was not within the 90 day window. However, upon speaking with the partner, it was determined they did do an orientation with her on her first date of employment but they did not have her sign the packet. The staff member was called and asked to sign the form and backdate for the date of the orientation. Upon the review, it was determined the orientation was ?doctored? and the staff member came in to sign a form with a backdate of 12/6/21 but on a recently updated October 2022 orientation form. The center will meet this requirement by using an electronic tracker that shows when orientation was completed for the new hire. It is the responsibility of the program manager to ensure this requirement is met within 90 days of hiring. We will not backdate orientation forms going forward.
Standard #:	8VAC20-780-240-B
Description:	Based on a review of staff records and interview on November 1, 2022, the center failed to ensure staff complete orientation training in subsection C of this section prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: 1. The record of staff #2, hired 11/11/21, contained documentation of orientation dated 2/17/22. 2. Administrator #1 indicated that staff #2 initially started with the Early Head Start program and submitted another documentation of orientation that was dated 12/6/21. 3. The documentation of orientation was signed and dated as completed on 12/6/21, however, the form completed indicated it was updated in October 2022 and therefore could not have been signed on 12/6/21. 4. Administrator #1 confirmed the form was ?doctored.?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-245-A
Description:	Based on a review of staff records and interview on November 1, 2022, the center failed to obtain an annual minimum of 16 hours of training appropriate to the age of children in care for each staff. Evidence: 1. The record of staff #3 contained documentation of 4 hours of training from6/13/21 to 6/13/22. 2. Administrator #1 acknowledged the annual training hours were not complete.
Plan of Correction:	The staff training tracker was submitted with the acceptable amount of hours. However, the supporting documentation was not in the staff file. Trainings need to be documented but the supporting documents attached when presented to licensing. The Program Manager will ensure the supporting documentation is filed in the staff file upon updating the training tracker. The training tracker is monitored at least quarterly to ensure staff are getting their 16 hours of annual training.