Lilly Grace LLC
1908 West Club Lane
Richmond, VA 23226
(804) 282-4482
Current Inspector: Sharon Curlee (804) 840-8312
Inspection Date: May 8, 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.
8VAC20-820 SANCTIONS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 BACKGROUND CHECKS
22.1 EARLY CHILDHOOD CARE AND EDUCATION
- Comments:
-
A monitoring inspection was conducted today, May 8, 2023. The inspector was on site from approximately 1:45 pm until 3:30 pm. The director was present and assisted in the inspection. There were 25 children present, ranging in ages from three months to two and a half years, with three staff. Upon the inspector?s arrival, children were napping. Two infants were in the swing. Later children played with toys on the mat and had a snack.
The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of six child records and seven 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.
If you have questions regarding this inspection, please contact the licensing inspector.
Sharon Curlee, Licensing Inspector
Office of Child Care Health and Safety
Division of Early Childhood Care and Education
804-840-8312
Sharon.curlee@doe.virginia.gov
- Violations:
-
Standard #: 22.1-289.035-A Description: Based on review of staff records, the center did not obtain a repeat background check every five years.
Evidence:
The record of staff #5, employed 05/18/2015, did not contain the results of a current central registry background report..Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 22.1-289.035-B-4 Description: Based on review of staff records and interview, the center did not request an Out of State Child Abuse and Neglect Search by the End of 30th Day of Employment
Evidence:
1. The record of staff #7, employed 01/23/2023, indicated the staff resided outside the state of Virginia in the past five years. The record did not contain documentation of an out of state child abuse and neglect search request for the state.
2. A member of management stated they were unaware an out of state background check was required.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 22.1-289.058 Description: Based on observation and interview, the center was not equipped with a carbon monoxide detector.
Evidence:
1.The center, licensed for children ages one month through two years six months did not have a carbon monoxide detector.
2.The director stated they did not have a carbon monoxide detector installed in the center.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-770-60-C-2 Description: Based on review of seven staff records and interview, the center did not obtain the results
of the central registry background report within 30 days of employment.
Evidence:
1. The record of staff #4, employed 12/21/2021, did not contain the results of a central registry
background report.
2. The record of staff #5, employed 05/18/2015, did not contain the results of a central registry
background report.
3. The record of staff #6, employed 03/08/2023, did not contain the results of a central registry
background report.
4. The record of staff #7, employed 01/23/2023, did not contain the results of a central registry background report.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-770-70-A Description: Based on review of staff records, the center did not obtain all required documentation for each staff record.
Evidence:
The record of staff #4 (employed 12/21/2021), staff #6 (employed 03/08/2023), and staff #7 (employed 01/23/2023), did not contain documentation of two or more references as to character and reputation as well as competency that were checked before employment or volunteering.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-160-A Description: Based on review of staff records, the center did not obtain documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. The documentation must have been completed within the last 30 calendar days prior to employment.
Evidence:
1. Staff #6, employed 03/08/2023, did not have documentation of a negative tuberculosis screening on file.
2. Staff #7, employed 01/23/2023, did not have documentation of a negative tuberculosis screening on file.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-160-C Description: Based on review of staff records, the center did not ensure staff obtained and submitted the results of a follow-up tuberculosis screening at least every two years from the date of the initial tuberculosis screening or testing.
Evidence:
1. The record of staff #1 contained documentation of a tuberculosis screening dated 04/23/2021, exceeding two years.
2. The record of staff #2 contained documentation of a tuberculosis screening dated 05/25/2019, exceeding two years.
3. Staff #5, employed 05/18/2015, did not have documentation of a negative tuberculosis screening on file. Staff #5 was observed working with children in care. I?m thinking that this should be moved to 160-C since DOH was in 2015Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-40-E Description: Based on observation and review of the license, the licensee did not ensure operational responsibilities, including compliance with the terms of the current license issued by the department.
Evidence:
During the inspection on 05/08/2023, the licensing inspector observed five infants sleeping in cribs in classroom #1. The current license stipulates: ?Room 1- A maximum of three cribs/3 children at any one time?.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-240-A Description: Based on review of staff records, the center did not ensure staff completed the Virginia Department of Education sponsored orientation course within 90 calendar days of employment.
Evidence:
1. The record of staff #4, employed 12/21/2021, did not contain documentation of completing the Virginia Department of Education sponsored orientation course within 90 days of employment.
2. The record of staff #7, employed 01/23/2023, did not contain documentation of completing the Virginia Department of Education sponsored orientation course within 90 days of employment.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-240-E Description: Based on observation and interview, the center did not ensure within 30 days of the first day of employment, staff received orientation training in first aid and cardiopulmonary resuscitation (CPR) as appropriate to the age of children in care.
Evidence:
1. There was no documentation of staff#4 (employed 12/21/2021), staff #6 (employed 03/08/2023), and staff #7 (01/23/2023) completing orientation training in first aid and CPR.
2. The owner stated she was not aware of the updated regulations regarding staff orientation and staff had not been oriented in first aid and CPR.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-245-L Description: Based on interview, the center did not ensure there was always at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children.
Evidence:
The director stated there were no staff with current daily health observation training.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-340-A Description: Based on observation and interview, the care and protection of five infants was not ensured.
Evidence:
1. Eight infants were observed in the infant room with 13 daily charts posted.
2. The inspector asked if any other infants were in care. The director stated five infants were sleeping in a separate room with a staff member due to them being light sleepers.
3. Upon entering the room, five infants were observed asleep in cribs with thick blankets. The infants were alone in the room with the door closed and without staff supervision for approximately 20 minutes.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-340-F Description: Based on observation and interview, the center did not ensure children under 10 years of age were always within actual sight and sound supervision.
Evidence:
Five infants were observed asleep in cribs in a room with the door closed. No staff were present in the room. The five infants were out of actual sight and sound supervision.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-350-B-1 Description: Based on observation and interview, the center did not maintain the required staff to child children ratio for children birth up to 16 months of age.
Evidence:
1. The required staff-to-children ratio for children birth up to 16 months is one staff for every four children. At the time of the inspector?s arrival, approximately 1:45 pm, there were 13 Infants in care with one staff member supervising.
2. The director stated staff were at lunch, one staff had scheduled off and the substitute had called out. The director acknowledged the infant class was out of ratio.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-440-J Description: Based on observation, the center did not ensure twelve inches of space was maintained between the sides and ends of occupied cribs.
Evidence:
In classroom #1, five occupied cribs were observed. The three cribs were touching end to end and did not have twelve inches of space maintained in between each crib.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-510-L Description: Based on observation and interview, the center did not ensure medications, except those prescriptions designated otherwise by written physician?s order, were kept in a locked place using a safe locking method that prevents access by children.
Evidence:
Prescription medication for child #7 was observed in a zipper bag hanging on the wall of the kitchen. The bag did not have a locking mechanism to prevent access by children in care.
The director acknowledged the medication was in an unlocked bag.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-540-C Description: Based on observation, the center did not maintain all required items in the first aid kit.
Evidence:
The first aid kit did not include gauze pads as required by the standard.Plan of Correction: Not available online. Contact Inspector for more information.
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.
