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Lucketts Community Center
42361 Lucketts Road
Leesburg, VA 20176
(703) 777-0357

Current Inspector: Tameika King (804) 629-7486

Inspection Date: Aug. 31, 2022

Complaint Related: Yes

Areas Reviewed:
8VAC20-780 Administration.
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code
63.2 Child Abuse & Neglect

Technical Assistance:
LI offered consultation regarding: training and supervision

Comments:
A complaint was received in the licensing office on 8/31/2022 regarding behavioral guidance, forbidden actions and program policies. The investigation was initiated on 8/31/2022 along with an additional local agency; there was a second licensing inspector present for all interviews. Interviews were conducted on and off site with all involved parties, video footage was observed and documentation was reviewed. The preponderance of evidence supports the allegation and the complaint is deemed valid. Violations found during the investigation can be viewed on the Violation Notice.

If you have any questions about this inspection, please contact Whitney McGrath, Licensing Inspector at whitney.mcgrath@doe.virginia.gov.

Violations:
Standard #: 22.1-289.035-B-4
Complaint related: No
Description: Based on record review, the center did not obtain an out-of-state background check by the end of the 30th day of employment for an employee that has resided outside of the state of Virginia within the last five years.
Evidence: Staff #1 (date of hire: 9/2/2021) sworn disclosure statement documented that they have lived outside of the state of Virginia in the last 5 years. Staff #1's out-of-state central registry background check is dated 4/29/2022.

Plan of Correction: The department?s original submission of the background check was dated 7/23/21, prior to the staff?s initial date of hire. The department also has email confirmation of receipt; however, the results were not received. Prior to the start of summer camp in 2022, this oversight was found and the out of state search was resubmitted. The results completed on 4/29/22, - again prior to the start of summer camp.

Corrective Action: PRCS will continue our process of submitting out of state searches prior to hiring, and document checklist will be used to ensure all results and required documents are received by the end of the 30 th day of employment. Additionally, all nationwide FBI fingerprint searches and central registry searches are completed with results prior to a start date.

Standard #: 8VAC20-780-40-E
Complaint related: Yes
Description: Based on a review of the centers policies and interviews, the operational responsibilities of the licensee did not ensure that the centers activities and services are maintained in compliance with these standards, the centers own policies and procedures that are required by these standards, and the terms of the current license issued by the department.
Evidence:
1. The center's behavioral guidance management policy states that ?General discipline techniques will include positive reinforcement for appropriate behaviors and careful explanation of behaviors that are unacceptable. Behavioral guidance shall be age and developmentally stage appropriate constructive in nature and shall be intended to redirect participants to appropriate behavior and resolve conflict.?
2. On 7/12/2022, staff #1 did not practice guidance that was age and developmentally appropriate when child #1 (age: 6 years old) was picked up and carried off the center playground and into the center. Staff #1 did not redirect child#1 to a more appropriate behavior or encourage conflict resolution.
3. The center's policies state ?PRCS staff are trained to use discipline techniques that are constructive, age-appropriate, and that focus on redirection and positive reinforcement.?
4. When asked how PRCS staff are trained to handle behavioral conflicts, staff #1 stated ?I have never been trained for a situation like this.?and ?No one has ever given me a straight answer on how to handle negative behaviors.? Staff #3 stated ?Our administration recognizes that we do not have enough training on behavioral management.?

Plan of Correction: The department has recognized the increase of challenging behaviors of children within our licensed programs since the impact of COVID. The Positive Behavioral Interventions and Supports model (PBIS) that has been incorporated into PRCS licensed staff training will be reviewed again with all licensed program staff. Additional training to focus on methods of de-escalation for children with behavioral issues will be required for staff to complete.

Prior to school starting in August, seven professional development trainings were offered to staff centered on behavior management, understanding behavior, and developing behavior plans with families. In September 2022, another in-person training was offered on Positive Behavioral Interventions and Supports model, that many, but not all staff attended. We also have recorded trainings in our online library to assign to staff who may be struggling with some behaviors on-site. We are constantly addressing staff needs, children?s needs, and will continue to provide trainings on behavior, making some of the trainings mandatory for all staff.

Standard #: 8VAC20-780-400-A
Complaint related: Yes
Description: Based on interviews and video footage obtained from the center, staff did not interact with children in order to promote the child's physical, intellectual, emotional and social well-being.
Evidence:
1. Staff #1, staff #2 and staff #5 reported that child #1 had hit children on the playground. When approached by staff #5 to discuss the hitting, child #1 ran away from the staff and crouched down next to a bench to avoid the discussion. Child #1 was refusing to talk to staff #5.
2. Staff #1 approached child #1 to discuss the hitting. The staff stated that they told the child if they cannot talk about what happened that they would need to ?go to the office.? Staff #1 stated that child #1 said ?I?m not using my words. I?m never using my words.? Staff #1 stated that they ?made a judgment call and picked [child #1] up to take them into the office.?
3. Staff #1 and staff #5 confirmed that child #1 was picked up and carried off the playground by staff #1. Once outside the playground gate, staff #1 continued to carry the child for approximately 12 feet and then put the child on the ground to walk. Staff #1 held child #1?s hand to walk into the school. At the front door of the school, child #1 is observed displaying labored breathing, hunched over. Staff #1 stated that child #1 ?started hyperventilating.? After approximately 30 seconds, staff #1 is observed opening the entrance door and attempting to pull the child inside. Child #1 is observed reaching for the door to resist entering the building. Once inside, the child continued to resist going into the office and was pulling the opposite direction as staff #1. Staff #1 picked the child up again by putting their arm around the child?s torso. Staff #1s arm slipped up the child's torso while the child flailed their body. Staff #1 repositioned by putting their hands under each armpit and carrying the child facing outward into the management office.
4. Staff #1, staff #2, staff #3 and staff #5 confirmed that staff carry walkie-talkies to be able to contact management if help is needed. Staff #1 and staff #5 stated that a walkie-talkie was in the medical bag on the playground and was not used when child #1 was resisting leaving the
playground.

Plan of Correction: The Loudoun County Department of PRCS concurs, in part, with the DOLP?s analysis of the incident. We concur that staff did not interact with the child to promote social well-being and growth, however, the staff intention was to promote the child?s physical well-being. There are areas that the department asks for amendments; as a point of clarification, Staff #1 did not state that the Child ?started hyperventilating? and we ask that this portion of the report be amended as such since no evidence can be found to support this statement. The incident occurred just after Child #1 hit three children in the chest in retaliation to the children calling him names. Staff #5 and Staff #1 followed protocol and initiated conflict resolution tools by encouraging child #1 to use their words to talk through conflict ? specifically, the aforementioned incident. On both instances, the child refused to use their words, refused verbal prompting to walk with Staff #1 to the office, and ran away from Staff #1 (remaining in the playground area). During this time, other children beginning to gather and observe the exchange between staff and Child #1. In an effort to deescalate the situation, staff felt it was best to remove Child #1 from the playground and take [the child] to the office to further discuss the incident and contact [the] parents Staff attempted to hold the child?s hand to go to the office pursuant to County policy; however, the child resisted and ran away from staff. Staff # 1 picked the child up briefly to go out of the fenced playground and put [the child] down on the sidewalk. Staff #1 walked hand in hand with child #1 to the front door. At the door, staff #1 paused with the child to give the child an opportunity to calm down as [the child] was upset. Staff #1 did not let go of child #1?s hand and when they began to go inside the door, the child resisted going inside. Video footage corroborates this information from the time the child was removed from the playground to the time the child was inside the center. The front door is located approximately 42 yards from a fence opening where the property ends, leading directly to busy Route 15. Child #1 has run way from staff previously and it was the child?s safety that staff #1 considered and to prevent [the child] from running toward a busy road. When the child resisted coming inside, staff #1 picked up the child, with arms under the child?s, to carry [the child] forward facing into the office. The child continued to resist. All efforts staff #1 took were intended to prevent harm, remove the child from an audience and get the child to a quiet place.

Corrective Action: The department recognizes COVID has impacted and increased the number of challenging behaviors of children within our licensed programs. PRCS currently uses the Positive Behavioral Interventions and Supports model (PBIS) for the licensed staff and training will be reviewed again with all current staff. Staff will be required to have refresher trainings on an annual basis. Stall will also be required to complete additional de-escalation training methods for children with behavioral concerns.

Loudoun County Dept of PRCS will be requesting a second step desk review.

Standard #: 8VAC20-780-410-1
Complaint related: Yes
Description: Based on interviews and review of video footage obtained from the center, rough handling was permitted.
Evidence: On 7/12/2022, staff #1 picked up and carried child #1 to remove them from the playground despite child #1 resisting physical contact.
2. Child #1 was observed displaying labored breathing at the front entrance of the center when staff #1 tried to take child #1 into the center, child #1 resisted by grabbing the center's front door. Staff #1 pulled the child into the building as the child pulled the opposite direction out of the building. Staff #1 put their arms around the child's torso.
3. Child #1 was flailing their body to resist staff #1. When the child slipped out of the staff's arms, staff #1 picked the child up again from under their arms, with the child facing outward and carried the child into the center's main office.

Plan of Correction: ? PRCS does not concur with this. No abuse was suspected at any time by any staff. The child?s parents contacted the Loudoun County Sheriff?s Office (LCSO), which investigated the incident. LCSO determined no criminal activity occurred and did not file any charges.
? Following the LCSO investigation, PRCS staff reported the incident to Loudoun County?s Child Protective Services (CPS), which is standard procedure.
? CPS also received a complaint from the parents directly. CPS conducted an investigation and found that allegations of physical abuse were unfounded.
? In addition, the Office of the Commonwealth?s Attorney (OCA) reviewed a criminal complaint that the child?s parents obtained through a Magistrate. The OCA also consulted with the family and reviewed the surveillance video. The OCA ultimately declined to prosecute.
? Even though these agencies indicated no abuse or criminal activity occurred or would be prosecuted, the Loudoun County Department of Human Resources (DHR) also conducted an internal investigation, which is a routine practice under these circumstances. DHR reviewed employees? performance and county and departmental administrative policies related to the incident. Where internal policy was not followed, appropriate action was taken in accordance with the county?s human resources policies.
? Multiple clips of surveillance video from the center?viewed in their entirety?refute claims that abuse occurred. These video clips viewed in their entirety?not as individual screen shots?helped to inform the decisions of LCSO, CPS, DHR, and OCA.
? The following describes the events captured on surveillance video on July 12:
o [13:08:27-13:18:48] Following an incident on the playground involving the child that necessitated the intervention of PRCS staff, the video shows a PRCS employee escorting the distraught child?who was behaving like a typical six-year-old child who is upset?from the playground to the community center. While exiting the playground, the employee briefly picked up the child and set [the child] on the walking path to the building, and then held [their] hand while walking [the child] to the entrance of the center.
o [13:08:27-13:08:48] Two video clips?one from the side and one from above the entrance?show the PRCS employee at the entrance of the building, calmly speaking with the child for about 25-30 seconds before entering the building.
o [13:08:28-13:08:48] While attempting to enter the building, the child pulled back and resisted going indoors, at which time the employee attempted to pick up the child. The child resisted and wiggled out of the employee?s hands. On a second attempt, the employee picked up the child under both arms and carried [them] for a few seconds into the center?s office space. The entire duration of this portion of the video clip is 5-7 seconds.
? Once inside a quiet space, PRCS staff attempted to console the child. Within an hour, PRCS staff contacted the child?s parents to inform them the child was involved in an incident on the playground and that the child had been quite upset.

Loudoun County Dept of PRCS will be requesting a second step desk review.

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.

Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. To find programs participating in Virginia Quality, click here.

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