VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fulton Montessori School
1620 Williamsburg Road
Richmond, VA 23231
(804) 893-7244

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: April 11, 2023

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) 20 Access to minors records 22.1 Background Checks Code, Carbon Monoxide 22.1 Early Childhood Care and Education

Comments:

An unannounced monitoring inspection was initiated and concluded on 4/11/2023. The inspector was on site from approximately 8:38 am-11:00 am. There were 31 children present, ranging in ages from 18 months to 6 years, with 8 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies, nutrition and background checks. A total of 5 child records and 5 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. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must 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 #:	8VAC20-780-140-B
Description:	Based on a review of five child records and interview, the center did not ensure that if a child has had a physical examination prior to attendance, it was within the required time period. Evidence: 1. The record of child #4 (age two at the time of enrollment: DOE 2/13/23) contained a physical dated 6/29/21. Physicals are required to be completed within 12 months prior to attendance for children two years of age through five years of age. 2. Administration acknowledged that the physical did not occur within the required time frame.
Plan of Correction:	4.11.23 Notified parent of child #4 of need to immediately provide an updated physical examination form that is from either within the last year from 2023. FMS administration will follow-up with parent in two day increments from today until the updated forms are provided to FMS.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of five staff records and interview, the center did not ensure to obtain documentation of a negative tuberculosis (TB) screening for one staff at the time of employment and prior to coming into contact with children. Evidence: 1. The record of staff #3 (date of employment: 4/10/23) did not contain a TB screening. 2. Administration acknowledged that the staff began employment prior to submitting a TB screening.
Plan of Correction:	1. Administration gave instructions to new employee to reschedule start date with FMS if TB form/test was incomplete before scheduled Mon 4.10.23 start date. New employee did not notify admin and FMS admin wrongly assumed form would be turned in before coming into the building on 4.11.23. New staff member has been placed on administrative leave as of 4.11.23 until TB screen and form is complete and submitted to FMS. Staff member said they were going immediately to get screening and form completed.
Standard #:	8VAC20-780-160-C
Description:	Based on a review of five staff records and interview, the center did not ensure to obtain documentation of a repeat tuberculosis (TB) screening for one staff at least every two years from the date of the first initial screening as required. Evidence: 1. The record of staff #5 (date of employment: 4/16/21) contained a TB screening dated 4/3/21. 2. Administration acknowledged that staff #5 had not completed the repeat TB screening.
Plan of Correction:	1. Staff #5 has scheduled her TB screening and is anticipated to turn in her completed results and DOE form on 4.12.23
Standard #:	8VAC20-780-270-A
Description:	Based on observation and interview, the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1. On the preschool playground, several wooden boards and posts on the fence were observed to be cracked and splintered. Two bikes were rusted and two bikes were missing handles and had seats with cracked vinyl. A sharp, rusted piece of metal was observed hanging from a playhouse. Children were observed using the broken play equipment. 2. Administration acknowledged that the areas required maintenance.
Plan of Correction:	FMS acknowledges the age of the fence is continually requiring close observation for splintering and warping boards that cause sharp edges. FMS will sand all areas that are protruding and will begin replacing wooden boards in need of replacement. FMS has removed all broken bikes and has repaired items that could repaired, and discarded unrepairable items. FMS removed the small metal rusted piece from the play area. All equipment is now safe and in good condition. FMS will also implement and plan for internal monthly building maintenance of indoors and outdoor spaces. Staff memo to clarify for all staff about what "clean, safe, operable" looks like.
Standard #:	8VAC20-780-550-D
Description:	Based on review of documentation and interview, the center did not ensure to implement a monthly practice evacuation drill. Evidence: 1. An evacuation drill was not documented in January and March of 2023. 2. Administration acknowledged that the drills had not been completed.
Plan of Correction:	FMS will ensure that a total of 4 drills occur by the end of April 2023. Evacuation Drill #2 occurred 4.11.23 at 3:48pm Scheduled: 4.20.23 Evacuation Drill #3 4.24.23 Evacuation Drill #4 5.3.23 Evacuation Drill #5 These drills have been scheduled on the FMS calendar with reminders set to ensure Admin will be prepared.
Standard #:	8VAC20-780-550-P
Description:	Based on review of documentation and interview, the center did not ensure that the minor injury records contained the required information. 1. A minor injury record from 2/3/2023 was reviewed that contained one staff signature. The records are required to contain a staff and parent signature or two staff signatures. 2. Administration acknowledged that the report was incomplete.
Plan of Correction:	2. Staff member who created form has been reminded to always either have parent sign or to have another staff member sign.
Standard #:	8VAC20-780-560-G
Description:	Based on observation and interview, the center dd not ensure that when food was brought from home that the containers were clearly dated and labeled in a way that identified the owner. Evidence: 1. Labels and dates were not observed on the children's food from home containers. 2. In interview, administration stated that they had created a system to label and date the food containers, but that it was not being utilized.
Plan of Correction:	FMS administration had new labelling system created for lunch boxes and will implement with parents and staff as of 4.12.23