VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lucketts Community Center
42361 Lucketts Road
Leesburg, VA 20176
(703) 777-0357

Current Inspector: Tameika King (804) 629-7486

Inspection Date: June 21, 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

Comments:

An unannounced investigation was conducted on 6/21/2023 regarding a self-reported incident that occurred on 6/19/2023. This visit was conducted between 9:30am and 11:00am. Interviews were conducted and video footage provided by the center was reviewed. After carefully interviewing the involved parties, violations have been issued and can be reviewed on the Violation Notice. Thank you for your cooperation during the investigation. If you have any questions, please e-mail me at whitney.mcgrath@doe.virginia.gov.

Violations:

Standard #:	8VAC20-780-40-E
Description:	Based on a review of the centers policies, video footage obtained from the center and interviews, the operational responsibilities of the licensee did not ensure that the centers activities and services are maintained in compliance with these standards, the centers own policies and procedures that are required by these standards. Evidence: 1.The program?s staff training handbook states "face to name attendance should be taken before and after each transition to different activities or areas in or out of the facility." 2. On 6/19/2023, Child #1 was registered to attend the program?s Child Care program when camp dismissed at 4pm. Staff #1 stated that they should have transitioned the child and completed a face to name check at the end of camp to the Child Care classroom. Staff #1 stated that they did not see Child #1 in the classroom at 4pm, so they had assumed that one of the Child Care staff had already transitioned the child to the appropriate classroom. Staff #1 confirmed that they marked ?CC? next to the child?s name in the Sign In/Sign Out book indicating that they had been transitioned to the Child Care classroom without completing a face to name check. 3.Child #1 was in the bathroom from approximately 3:29pm until 4:35pm. The child was never transitioned to the Child Care classroom.
Plan of Correction:	Drop-in childcare procedures have been amended. Requests for drop-in care must now be approved 48 hours in advance. Staff have received a refresher training, which included transitioning children from one activity to another using name-to-face attendance tracking. Sign-in/sign-out procedures have been reviewed and enhanced to ensure accuracy with all staff present. The bathroom door in classrooms will remain open unless in use. Staff will do a sweep of the classroom and verify attendance prior to transitioning to other areas. The updates to policies will be communicated to the parents of children in care.
Standard #:	8VAC20-780-340-A
Description:	Based on interview and video footage obtained from the center, staff did not always ensure their care, protection and guidance when supervising children. Evidence: 1. One 6/19/2023, at approximately 3:29pm, Child #1 (5 years old) runs to the bathroom in the upstairs camp classroom. 2. Child #1 was alone in the classroom from approximately 4:25pm until 4:35pm. 3. Staff #1, Staff #2 and Staff #3 were unaware that Child #1 was in the bathroom for approximately 1 hour and 6 minutes. 4. Child #1?s parents arrived at the facility at approximately 4:30pm and the child could not be located. 5. Child #1 was in the bathroom until approximately 4:35pm. 6. Staff #1 stated that when they did not see Child #1 in the classroom at 4pm, they had assumed that one of the Child Care staff had already transitioned the child to the appropriate classroom. Staff #1 confirmed that they marked ?CC? next to the child?s name in the Sign In/Sign Out book indicating that they had been transitioned to the Child Care classroom without observing or verifying the child left the room.
Plan of Correction:	Staff have received a refresher training, which included transitioning children from one activity to another using name-to-face attendance tracking. Sign-in/sign-out procedures (including roster changes) have been reviewed and enhanced to ensure accuracy with all staff present. The bathroom door in classrooms will remain open unless in use. Bathroom checks will be conducted every 15 minutes. Staff will do a sweep of the classroom and verify attendance prior to transitioning to other areas. The updates to policies will be communicated to the parents of children in care. The Licensed Program Manager has scheduled an additional training on Active Supervision, which will be completed in August.
Standard #:	8VAC20-780-340-F
Description:	Based on video footage obtained from the center, children under 10 years of age were not always within actual sight and sound supervision of staff. Evidence: 1. On 6/19/2023, at approximately 3:29pm, Child #1 (5 years old) runs to the bathroom in the upstairs camp classroom. 2. At approximately 4:14pm, Staff #1 leaves the classroom. 3. At approximately 4:25pm, Staff #2 and Staff #3 leave the classroom. 4. Child #1?s parents arrive at the facility at approximately 4:30pm and the child cannot be located. 5. At approximately 4:35pm, Staff #1 runs into the upstairs classroom and locates Child #1 in the bathroom. 6. Staff confirmed that they were unaware Child #1 had entered the classroom bathroom. 7. Child #1 was not within actual sight and sound supervision for approximately 1 hour and 6 minutes.
Plan of Correction:	Staff have reviewed steps to ensure all children are being actively supervised and accounted for while in care. Staff have received a refresher training, which included transitioning children from one activity to another using name-to-face attendance tracking. Sign-in/sign-out procedures (including roster changes) have been reviewed and enhanced to ensure accuracy with all staff present. The bathroom door in classrooms will remain open unless in use. Staff will do a sweep of the classroom and verify attendance prior to transitioning to other areas. The updates to policies will be communicated to the parents of children in care. The Licensed Program Manager has scheduled an additional training on Active Supervision, which will be completed in August.
Standard #:	8VAC20-780-340-I
Description:	Based on interview and video footage obtained from the center, staff did not oversee each child's departure from the center. Evidence: 1. On 6/19/2023, Child #1 was registered to attend the program?s Child Care program when camp dismissed at 4pm. Staff #1 stated that they should have transitioned the child and completed a face to name check at the end of camp to the Child Care classroom. Staff #1 stated that they did not see Child #1 in the classroom at 4pm, so they had assumed that one of the Child Care staff had already transitioned the child to the appropriate classroom. Staff #1 confirmed that they marked ?CC? next to the child?s name in the Sign In/Sign Out book indicating that they had been transitioned to the Child Care classroom without completing a face to name check. 2.Child#1 was located in the upstairs camp classroom bathroom at approximately 4:35pm.
Plan of Correction:	Drop-in childcare procedures have been amended. Requests for drop-in care must now be approved 48 hours in advance. Staff have received a refresher training, which included transitioning children from one activity to another using name-to-face attendance tracking. Sign-in/sign-out procedures have been reviewed and enhanced to ensure accuracy with all staff present. The bathroom door in classrooms will remain open unless in use. Staff will complete a sweep of the classroom and verify attendance prior to transitioning to other areas. The updates to policies will be communicated to the parents of children in care.