VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Children of America Salem Church, LLC
12008 Old Salem Church Rd
Fredericksburg, VA 22407
(540) 548-1555

Current Inspector: Donna Liberman (540) 359-5244

Inspection Date: Dec. 21, 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. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced monitoring inspection was conducted from 11:00 am - 2:30 pm with the center director. There were 91 children, ranging from three months to ten years of age, present with 16 staff supervising. Children were observed playing with age-appropriate toys, washing hands and preparing for lunch, eating lunch and napping. Lunch served today: turkey ham on a whole wheat bun, broccoli, pears and milk. Ten child records and eleven staff records were reviewed, along with the emergency drill log, written daily attendance, written allergy list, five medications and authorization forms. Please complete the columns for "Plan of Correction" and "Date to be Corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office by 4:00pm on Monday, 1/23/2023. If you have further questions about this inspection please contact Donna Liberman at 540-359-5244 or Donna.Liberman@doe.virginia.gov.

Violations:

Standard #:	22.1-289.035-B-4
Description:	Based on review of eleven staff records, it was determined that no Out of State Child Abuse and Neglect Search was requested by the end of the 30th day of employment or Criminal History Name Check prior to employment was obtained for staff who indicated they have lived outside of Virginia in the past five years and/or follow up as required. Evidence: the record for staff #10 (Date of hire: 7/11/2022), who indicated that they have lived out of the state of Virginia in the past five years, had no documentation of an out of state child abuse and neglect search request. The record for staff #7, (Date of hire: 11/8/2021) who indicated that they have lived out of the state of Virginia in the past five years, had no documentation of an out of state child abuse and neglect search request or criminal history name check.
Plan of Correction:	All out of state checks are submitted. Tracking of status check on each file.
Standard #:	8VAC20-770-60-C-2
Description:	Based on review of eleven staff records, it was determined that not all staff had Central Registry Search results within thirty days of employment and/or follow up conducted as required. Evidence: The record for staff #1 (Date of hire: 11/10/2021), staff #6 (Date of hire: 10/31/2022), staff #8 (Date of hire: 3/7/2022) did not have documentation of a Central Registry search report or evidence that follow up was conducted in the required time frame.
Plan of Correction:	Central Registry completed for all staff
Standard #:	8VAC20-780-130-A
Description:	Based on a review of seven child records, the facility did not obtain documentation that each child has received immunizations prior to the child's first attendance. Evidence: the record for child #5 (date of first attendance: 7/5/2022 did not have documentation of immunizations.
Plan of Correction:	All immunization forms updated
Standard #:	8VAC20-780-140-A
Description:	Based on a review of seven child records, the facility did not obtain documentation that each child has received a physical examination prior to the child's first attendance or within one month after attendance. Evidence: the record for child #2 (date of first attendance: 6/27/2022), child #6 (date of first attendance: 7/5/2022 and child #6 (date of first enrollment: 9/6/2022) did not have documentation of a physical examination.
Plan of Correction:	All physical forms updated
Standard #:	8VAC20-780-160-C
Description:	Based on review of eleven staff records, not all staff had a repeat tuberculosis (TB) test/screening at least every two years from the date of the previous test/screening. Evidence: the record for staff #11 had a TB test/screening dated: 5/26/2020.
Plan of Correction:	All TB tests/screenings up to date
Standard #:	8VAC20-780-60-A
Description:	Based on review of seven child records, it was determined that not all records contained all required information. Evidence: the records for child #2 and child #3 did not have complete information for two emergency contacts.
Plan of Correction:	Information completed
Standard #:	8VAC20-780-70
Description:	Based on review of eleven staff records, not all records contained all required information. Evidence: the record for staff #5 (date of hire: 9/16/2020), staff #8 (date of hire: 3/7/2022) and staff #10 (date of hire: 7/11/2022) did not have complete documentation that two or more references were checked before employment.
Plan of Correction:	Form corrected with dates
Standard #:	8VAC20-780-340-A
Description:	Based on observation, the facility failed to ensure the children?s care, protection and guidance regarding safe sleep practices. Evidence: 1) an infant was observed sleeping with a pacifier attached to a ribbon and wearing a bib which is a choking hazard. 2) there were multiple blankets hanging from the sides of cribs, and blankets and bibs observed inside cribs that staff stated were in use by infants. 3) unsafe sleep conditions increase the risk of sudden unexplained infant death.
Plan of Correction:	All blankets, bibs, and pacifier strings are placed in cubbies
Standard #:	8VAC20-780-500-A
Description:	Based on observation, and an interview with staff, not all handwashing procedures were followed, as required. Evidence: staff in the infant A classroom was observed changing a child's diaper and staff did not wash the child?s hands with soap and water afterwards. Staff stated that they used a baby wipe.
Plan of Correction:	Retrained on handwashing procedures for all age groups
Standard #:	8VAC20-780-510-E
Description:	Based on review of five medications and authorizations, it was determined that the facility failed to follow their medication procedures as required. Long term prescription drug use and over-the-counter medication may be allowed with written authorization from the child?s physician and parent. Evidence: the record for child #9 did not contain written authorization from the parent for long term medication observed on site.
Plan of Correction:	All forms and medication checked
Standard #:	8VAC20-780-510-P
Description:	Based on review of five medications and authorizations, the facility did not ensure when an authorization for medication expires, the parent was notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Evidence: Two medication authorization forms for child #8 expired 10/2021 and one medication authorization form for child #9 expired on 9/15/2022. The medication has not been returned to the parents nor have the parent renewed the medication authorization forms.
Plan of Correction:	All forms updated
Standard #:	8VAC20-780-520-C
Description:	Based on review of diaper ointment observed on site, the facility failed to maintain a record that includes the child?s name, date of use, frequency of application and any adverse reactions. Evidence: the record for child #10, with diaper ointment on site, did not contain a record of use. Staff stated that the ointment was used but they did not maintain a record of use, as required.
Plan of Correction:	Each classroom has a binder with forms to document. Staff retrained.
Standard #:	8VAC20-780-550-F
Description:	Based on review of documentation, not all lockdown drills were practiced at least annually as required. Evidence: The last documented lockdown drill was conducted on: 8/7/2021.
Plan of Correction:	All drills forms up to date