VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesterbrook Academy #819
12960 Troupe Street
Woodbridge, VA 22192
(703) 878-1220

Current Inspector: Donna Liberman (540) 359-5244

Inspection Date: Feb. 16, 2023

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Special Care Provisions and Emergencies. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced focused inspection was conducted on 2/16/23 from 12:15pm to 2:10pm with the Director. There were 73 children in care, ranging in age from four-months to five-years-old, supervised by 12 staff. The children were observed finishing lunch, napping, and doing quiet activities on their cots. Three child records and two staff records were reviewed. Eight medications and authorization forms were reviewed and the center has five staff current in Medication Administration Training (MAT). The attendance was reviewed. The most recent Fire Inspection on file was dated 11/22/21. If you have questions regarding this inspection, please contact the Licensing Inspector, Laura Brindle, at laura.brindle@doe.virginia.gov or 540-905-2062. Please complete the "Plan of Correction" and "Date to be Corrected" areas on the Violation Notice for each violation cited and return to me by close of business on 3/3/23. Plans of correction should include steps to correct the noncompliance with the standard, and measures to prevent the noncompliance from occurring again.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on review of two staff records, the center did not obtain documentation of the findings of a fingerprint-based national criminal history record check prior to employment for one staff. Evidence: The record for Staff #2, with an employment date of 11/28/22, contained documentation of fingerprints results dated 12/30/22.
Plan of Correction:	Hire date and start date differed. Staff did not start without results. Results are in our possession.
Standard #:	8VAC20-780-160-A
Description:	Based on review of two staff records, the center did not ensure that each staff member submitted documentation of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children; or within the last 30 calendar days of the date of employment. Evidence: 1. The record for Staff #2, with an employment date of 11/28/22, contained documentation of a TB screening dated 12/9/22. 2. The record for Staff #1, with an employment date of 11/28/22, contained documentation of a TB screening dated 1/7/22.
Plan of Correction:	Staff TB results will be collected before hire date.
Standard #:	8VAC20-780-60-A
Description:	Based on review of three child records, the center did not obtain all of the required documentation for each child record. Evidence: 1. The records for Child A and Child B did not contain the name, address, and phone number of a second designated person to call in an emergency if a parent could not be reached. 2. The records for Child A and Child C did not contain documentation of viewing proof of the child's identity and age.
Plan of Correction:	Second emergency contact obtained. Child's birth certificate verified and a copy placed on file.
Standard #:	8VAC20-780-260-A
Description:	Based on review of documentation and interview, the center did not provide to the licensing representative an annual fire inspection report. Evidence: The most recent fire inspection report on record was dated 11/22/21. The Director confirmed this was the most recent fire inspection.
Plan of Correction:	Fire Inspection was conducted on 1/4/2023. Fire Marshall returned and gave report.
Standard #:	8VAC20-780-510-E
Description:	Based on review of medication and medication authorization forms, the center's procedures for administering medication did not include methods to prevent use of outdated medication. Evidence: On 2/16/23 an emergency medication was observed in the medication box that had an expiration date of 11/2/22. The director reported that they did not realize it had expired.
Plan of Correction:	The child had transitioned from our facility and medication left in error. Medication removed.
Standard #:	8VAC20-780-510-P
Description:	Based on review of medication and medication authorization forms, the center did not ensure that when an authorization for medication expired, the parent was notified that the medication needed to be picked up within 14 days or the parent must renew the authorization and medications that were not picked up by the parent within 14 days were not disposed of by the center. Evidence: On 2/16/23 a prescription diaper cream was observed in the medication box at the center. The parent authorization for short-term medication was dated 11/22/22 and expired on 12/1/22.
Plan of Correction:	Medicated diaper cream returned to parent.