VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Orange County Government-Office on Youth (Locust Grove)
31230 Constitution Highway
Locust grove, VA 22508
(540) 854-9088

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: July 24, 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) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced monitoring inspection was conducted on-site July 24, 2023. The director was available during the inspection. There were 30 children present, ranging in ages from 5 years to 11 years, with 2 staff supervising. 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 7 child records and 4 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. 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 preventative measures. Please do not use staff names; list staff by positions only.

Violations:

Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of staff records, the center failed to ensure each staff record reviewed contained a central registry finding within 30 days of employment. Evidence: The record of staff #3, hired 03/06/2023, contained documentation of central registry results dated 06/07/2023.
Plan of Correction:	Moving forward, administration will ensure this paperwork is received and submitted in time. Timelier follow-up with the CRS system will be documented.
Standard #:	8VAC20-780-40-E
Description:	Based on a review of the medication policy and interview, the licensee failed to ensure that the center's activities, services, and facilities are maintained in compliance with the center's own policies and procedures that are required by these standards, and the terms of the current license issued by the department. Evidence: 1. On page 18 of the center handbook titled "Orange County School Age Child Care" it states "medication will only be given to children when parents have supplied the appropriate OCSACC Medication Authorization Form, with ALL INFORMATION completely filled out." 2. On June 14, 2023, child #2 was given children's Ibuprofen. The record of child #2 did not contain documentation of parent authorization to administer the medication. Staff #2 confirmed there was no parent authorization available for child #2. 3. On July 24, 2023, child #1 was given prescription Ventolin. The record of child #1 did not contain documentation of parent authorization to administer the medication. Staff #2 confirmed there was no parent authorization available for child #1.
Plan of Correction:	One medication authorization was located on-site after the inspection and was to be filed appropriately. The Operations Manager will follow-up on this form and the second medication that was found on-site without a permission form. If the form cannot be located, a new form will be requested or the medication will be returned to the parent until a new form is received. Additionally, staff will be reminded that meds cannot be given without the proper documentation.
Standard #:	8VAC20-780-60-A
Description:	Repeat Violation Based on a review of children's records and interview, the center failed to ensure that each child's record contained the required information. Evidence: 1. The record of child #2 did not contain documentation of the first date of attendance, written agreements between the parent and the center, proof of identity, immunizations, and a physical. 2. The record of child #3 did not contain documentation of, the first date of attendance, written agreements between the parent and the center, proof of identity, immunizations, and a physical. 3. Staff #2 reported that the center did not have authorization from the parents to obtain the information from the school.
Plan of Correction:	The Operations Manager will be visiting the site on 08/03 to review files and work with the Site Manager to request missing paperwork from parents. Moving forward, the internal inspections that the Operations Manager will be conducting will include pulling children's files to spot check and ensure paperwork is completed. This will include all four sites and not just LGPS.
Standard #:	8VAC20-780-240-A
Description:	Repeat Violation Based on a review of staff records and interview, the center failed to ensure that staff complete the Virginia Department of Education sponsored orientation course within 90 calendar days of employment. Evidence: The record of staff #3, hired 03/06/2023, did not contain documentation of the Virginia Department of Education sponsored orientation. Staff #4 confirmed the orientation was not completed.
Plan of Correction:	Administration and Site Managers will ensure staff are completing required training in a timely manner. Staff will be removed from the schedule if deadlines cannot be met.
Standard #:	8VAC20-780-350-B-5
Description:	Based on observation and interview, the center failed to ensure that for children, from the age of eligibility to attend public school through eight years, one staff member for every 18 children is maintained at all times children are in care. Evidence: 1. At 2:20pm the licensing inspector observed 30 children in care in the cafeteria with two staff supervising. Staff #2 verified the youngest child in care was five years old. 2. At 2:20pm staff #1 took one child to the bathroom, leaving staff #2 with 29 children. 3. At 2:21pm another child left the cafeteria and staff #2 was not aware. That child came back immediately. 4. At 2:23pm staff #2 sent two children to the bathroom with staff #1, leaving staff #2 with 27 children. 5. At 2:24pm four children were picked up from a parent, leaving staff #2 with 23 children. 6. At 2:25pm three children returned from the bathroom, leaving staff #2 with 26 children. 7. At 2:26pm staff #1 returned and took five children to the bathroom, leaving staff #2 with 21 children. 8. At 2:27pm two children returned to the cafeteria and staff #2 was not aware. Staff #2 had 23 children in care alone. 9. At 2:29pm two children returned to the cafeteria, leaving staff #2 with 25 children. 10. At 2:30pm staff #1 returned with one child. 11. Staff #2 confirmed she was not aware that the staff to children ratio had to be maintained during bathroom breaks and that the center did not maintain the required ratio for 10 minutes.
Plan of Correction:	Ratios will be addressed to the staff that include taking children to the bathroom. This is a first write-up for us on this issue and we will adjust accordingly.
Standard #:	8VAC20-780-510-F
Description:	Based on a review of two medications and interview, the center failed to ensure the medication authorization for two medications were available to staff during the entire time they were effective. Evidence: 1. On July 24, 2023, one medication was observed on-site for child #1. There was no documentation of medication authorization in the record of child #1. Staff #2 reported there was no parent authorization for medication on file for child #1. 2. On July 24, 2023, one medication was observed on-site for child #2. There was no documentation of medication authorization in the record of child #2. Staff #2 reported there was no parent authorization for medication on file for child #2.
Plan of Correction:	One medication authorization was located on-site after the inspection and was to be filed appropriately. The Operations Manager will follow-up on this form and the second medication that was found on-site without a permission form. If the form cannot be located, a new form will be requested or the medication will be returned to the parent until a new form is received.