VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Grace Montessori School
6507 Main St
The plains, VA 20198
(540) 253-5177 (105)

Current Inspector: Sharon Allen (540) 272-2941

Inspection Date: Nov. 14, 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. 8VAC20-790 Subsidy Regulations. 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 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Technical Assistance:

1. Sibling groups require separate files and paperwork. 2. Consultation provided on children with persistent behavioral issues. 3. You must remove the dome climber or the swings as their fall zones overlap. 4. More attention is required to staff files to include obtaining all of the required information and background checks before employment. 5. Background Check Not Requested or Expired. If there is a violation where no background check request has been submitted or background checks have expired for a staff member, the provider must provide the Licensing Inspector (LI) documentary proof that the request has been submitted, as soon as possible, but no later than 10 business days following notification; and The provider must also, upon receipt, send documentation to the LI of the date that the background checks were received. ? Method for Provider to Send Documentation. The provider may scan/email, mail, or drop the information off at the LI?s office. Fax should not be used due to confidentiality issues. ? Personal Information Should Be Redacted. Before submission to the LI, all documentation should have Personally Identifying Information (PII) such as social security numbers, personal addresses and birthdates redacted.

Comments:

An unannounced monitoring inspection was conducted today from 10:25 am to 1:20 pm. The ages of the children ranged from 18 months to 5 years. The first half of the inspection was conducted with two lead teachers and the second half of the inspection was conducted with the new director. Seventeen children were present with 5 staff providing supervision. The Licensing Inspector was able to observe group activities, lunch time, transitions and outside playtime. Food is brought from home. A sample size of 6 injury /accident reports were reviewed. There were no medication on stie for any of the children. The health inspection was dated 2/18/22 and the fire inspection was dated 8/19/22. The areas of non compliance are outlined on the violation notice

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on a review of 7 staff files and an interview with the director, it was determined that fingerprint background checks were not obtained for all staff prior to their first day of employment. Evidence: Staff B was hired on 10/18/22 and there was no fingerprint background check on file. Staff C was hired 9/9/22 and there was no fingerprint background check on file. Staff D was classified as a volunteer however they are functioning as a staff. Staff D came on board in 9/22 and does not have a fingerprint background check on file.
Plan of Correction:	We will send off for the background checks and send our inspector copies of the completed checks. In the future, we will not hire staff without these background checks.
Standard #:	8VAC20-770-60-B
Description:	Based on a review of staff files and an interview with the director, it was determined that staff did not have a sworn disclosure statement on file prior to the first day of employment. Evidence: Staff B, C and D did not have sworn disclosure statements on file.
Plan of Correction:	We will obtain sworn disclosure statements and in the future we will not hire staff without first obtaining these background checks.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of 7 staff files and interview with the director, it was determined that 3 staff did not have central registry findings on file within 30 days of employment. Evidence: Staff B, C and D did not have their central registry background checks on file within 30 days of employment.
Plan of Correction:	We will immediately send off for these background checks and send our Inspector copies once completed. In the future we will make sure to send off for these checks within 7 business days and check on the status if we haven't received them by the 30th day.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of staff files and interview with the director, it was determined that staff B, C and D did not have tuberculosis tests/screenings on file at the time of employment.
Plan of Correction:	We will get the tuberculosis test/screening.
Standard #:	8VAC20-780-160-C
Description:	Based on a review of staff files and an interview with the director, it was determined that two staff ( A and E) did not have repeat tuberculosis test/screening every two years from the date of the initial screening. Evidence: Staff A's tuberculosis test is dated 10/27/20 and staff B's tuberculosis test is dated 8/7/19.
Plan of Correction:	We will get the tuberculosis test/screenings.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of six children's files and an interview with the director, it was determined that the center did not maintain a separate record for a sibling group. Evidence: Child A and B are a sibling group and they share one file and the required paperwork.
Plan of Correction:	We will obtain the required information for the files.
Standard #:	8VAC20-780-60-A-8
Description:	Based on a review of recordkeeping and interview with the director, it was determined that child C did not have a written allergy care plan on file for the diagnosed food allergy of eggs and peanuts.
Plan of Correction:	We will obtain the allergy care plan.
Standard #:	8VAC20-780-70
Description:	Based on a review of 7 staff files and interview with the director, it was determined that 3 staff ( B, C and D) did not have record information to include job title, references, educational requirements, first aid/CPR certifications and health information.
Plan of Correction:	We will obtain the required information for the staff files.
Standard #:	8VAC20-780-240-B
Description:	Based on a review of staff files and interview with the director, it was determined that 3 staff had not been given orientation training within 7 days of assuming job responsibilities. Evidence: Staff B, C and D had not been given orientation training. Staff B was hired 10/18/22, staff C was hired 9/8/22 and staff D was hired in 9/22.
Plan of Correction:	We will provide and documents the orientation training.
Standard #:	8VAC20-780-280-B
Description:	Based on observation it was determined that hazardous substances were not kept locked. Evidence: The Licensing Inspector observed disinfectant wipes and all purpose cleaner on a shelf in the closet in the 3 to 5 year old classroom. The closet door was not locked.
Plan of Correction:	We will make sure all hazardous substances are kept locked.
Standard #:	8VAC20-780-330-B
Description:	Based on observation, measurement and interview with the director, it was determined that there was insufficient resilient surfacing on the playground and overlapping fall zones. Evidence: 1. There was no resilient surfacing (mulch) on the sides of the swings, the standards requires 6 inches of mulch 6 feet on both sides of the swings. 2. The dome climber requires a 6 foot fall zone and the swings requires a 17' 8" fall zone to the front of the swings. The dome climber and swing fall zone overlaps by 6 feet.
Plan of Correction:	We will place the dome climber off limits with signage and caution tape until we can remove it. We will add the mulch to the sides of the swings.