VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesterbrook Academy
2920 Old Pump Road
Richmond, VA 23233
(804) 360-4141

Current Inspector: Cindy Horne (804) 297-4469

Inspection Date: May 30, 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 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

Please review The American Academy of Pediatrics guidance for safe sleep practices and the AAP?s recommendation against using infant swings for sleep.

Comments:

A monitoring inspection was conducted on 05/30/2023 from approximately 9:00 a.m. ? 3:05 p.m. There were 93 children present ranging from infants to school agers and 13 staff supervising. The inspector reviewed compliance in the areas of administration, qualifications and training, physical plant, staffing and supervision, programming, medication, special care and emergencies, and nutrition. Ten child records and ten staff records were reviewed. The information gathered during the inspection determined violations with applicable standards or law. A violation notice was issued. 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, 06/20/2023. Please specify how the deficient practice will be or has been corrected. Your plan of correction should 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 preventive measure(s).

Violations:

Standard #:	8VAC20-770-60-C-2
Description:	Based on staff record review, the provider failed to obtain a search of the central registry within 30 days of employment. Evidence: The record for S6, employed 11/08/2022 did not have results of a central registry search within 30 days of employment. The results of the central registry search for S6 are dated 12/13/2022.
Plan of Correction:	Central Registry reports will be dated with the date of request. In the event there is a delay with Central Registry sending the report, we will have documentation of the date it was requested. The new director will be doing these on line going forward with documentation of when the report was requested. The process has already begun.
Standard #:	8VAC20-780-130-E
Description:	Based on child record review, the provider failed to obtain documentation of additional immunizations once every six months for children under the age of two years. Evidence: The record for C6 did not contain the immunization record due by 05/10/2023 before the child become 2 years old.
Plan of Correction:	We will have parents bring in immunization forms prior to their child's well visit with their doctor if the appointment is a day or more after their birthday. Children who are under 2 years old will be required to submit immunization records every 6 months following the exact date of their previous records. All children's records will be reviewed monthly to ensure compliance with Virginia licensing. The director and assistant director will have all files completely checked by June 30, 2023.
Standard #:	8VAC20-780-140-B
Description:	Based on record review, the provider failed to ensure that each child shall have a physical examination by or under the direction of a physician within three months prior to attendance for children between seven months through 18 months. Evidence: The record for C9, enrolled 02/27/2023 documented the child are under the age of 18 months and the physical exam was conducted outside the three-month period. The physical examination for C9 was dated 11/15/2022.
Plan of Correction:	This record was 12 days over the 3-month timeframe for a physical. All files will be reviewed prior to the child's start date to verify the record is not older than three months. This new process has already begun. The director or assistant director will review new enrollment documents on the actual day the child starts to ensure it has not passed the allowed timeframe.
Standard #:	8VAC20-780-240-A
Description:	Based on record review, the provider did not ensure that two of ten staff completed the Virginia Department of Education (VDOE) sponsored orientation course within 90 calendar days of employment. Evidence: The records for S6, employed 11/08/2022 and S7, employed 02/08/2023 did not document completion of the 10-hour VDOE sponsored orientation course.
Plan of Correction:	Employees are now required to complete the 10 preservice prior to their first day of employment. This new procedure has already begun. The director will verify this training is complete prior to the hire date.
Standard #:	8VAC20-780-520-C
Description:	Based on review of written parental authorization forms for diaper cream use and interview, the provider failed to obtain parental authorization for the specific cream used on a child. Evidence: The written parental authorization form for C11 documented permission to use Butt Paste diaper cream. The staff reported no longer having Butt Paste available but Triple Paste provided by the parents. Staff reported not obtaining an updated the parental authorization. The written parental authorization form for C12 documented permission to use Destin. The staff reported using Aquaphor provided by the parents. Staff reported not obtaining an updated the parental authorization.
Plan of Correction:	Forms will reflect the correct name of the diaper rash cream. This was corrected immediately. The director and assistant director will monitor any new forms for diaper rash cream and continue monitoring classrooms to make sure the correct brand name of the cream being used is listed.
Standard #:	8VAC20-780-560-G
Description:	Based on observation, the provider failed to ensure food brought from home was clearly dated and labeled in a way that identifies the owner. Evidence: Licensing inspector observed a lunch box in the Infant II classroom refrigerator that was not dated.
Plan of Correction:	Lunch boxes stored in the refrigerator will be labeled with name and date. This was corrected immediately. The director and assistant director have relayed the labeling requirements to employees and will continue to monitor refrigerators.