VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Celebree School of Henrico
3641 Cox Road
Henrico, VA 23233
(804) 415-4991

Current Inspector: Tara Barton (804) 381-8487

Inspection Date: Aug. 22, 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. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Comments:

A monitoring inspection was conducted on August 22, 2023 with center management. There were 80 children present, ranging in ages from 3 months to 5 years, with 17 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 8 child records and 8 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. Time of today?s inspection: 12:00 p.m. to 3:40 p.m. Please call me if you have any questions at 804-381-8487 or e-mail tara.barton@doe.virginia.gov.

Violations:

Standard #:	8VAC20-770-60-C-2
Description:	Based on review of eight staff records, the facility failed to have documentation of a completed search of the central registry (CPS check) on file for each staff within the first 30 days of employment. Evidence: Staff 8 (date of employment 7/5/2023) did not have a completed search of the central registry on file. There was no documentation of having submitted the search of the central registry within 7 days of employment as required.
Plan of Correction:	CPS checks will be submitted within 7 days as required. If they are not returned within 30 days, the central Registry office will be contacted for follow up.
Standard #:	8VAC20-780-160-A
Description:	Based on review of 8 staff records, the facility failed to have documentation of a tuberculosis test or screening signed by a physician, physician's designee, or an official of the local health department. Evidence: Staff 1 had a tuberculosis screening dated 3/18/2023 signed by a dental assistant. Staff 6 had a tuberculosis screening signed by an individual that did not indicate credentials or identify the physician with which the designated screener is affiliated.
Plan of Correction:	"We have asked our teachers to take a new TB Screen and they are working on scheduling the appointment."
Standard #:	8VAC20-780-70
Description:	Based on review of eight staff records, the facility failed to have required documentation in each file. Evidence: Staff 1 (date of employment 3/20/2023) and Staff 6 (date of employment 2/1/2023) did not have documentation to demonstrate that the individual possesses the education and experience required by the job position. Staff 7 (date of employment 8/3/2023) and Staff 8 (date of employment 7/5/2023) did not have documentation of two references as to character, reputation, and competence prior to employment, as required.
Plan of Correction:	Per owner reference are completed. Working on obtaining documentation of qualifications.
Standard #:	8VAC20-780-240-C
Description:	Based on review of eight staff records, the facility failed to have documentation of orientation, including all required facility specific topics. Evidence: Eight staff did not have documentation of orientation - that included all required facility specific topics- on file.
Plan of Correction:	Per owner: "We have added the new orientation checklist as part of the employee onboarding. This will be done for all new employees going forward."
Standard #:	8VAC20-780-245-J-3
Description:	Based on documentation review and staff interview, the facility failed to ensure that any child for whom emergency medications have been prescribed shall always be in the care of a staff member or independent contractor who meets the requirements as described in 8VAC20-780-245.J.1 for medication administration. Evidence: Child A (date of enrollment 6/19/2023) has an emergency medication which is to be administered rectally on site. None of the staff caring for the child are certified in Medication Administration Training - Rectal Medications.
Plan of Correction:	An administrator completed the training 8/29/2023. Three teachers have completed the trainings 9/1/2023.
Standard #:	8VAC20-780-260-A
Description:	Based on review of inspection reports, the facility failed to ensure that an annual fire inspection was conducted by the appropriate fire official having jurisdiction. Evidence: The last fire inspection on file was dated 6/23/2022.
Plan of Correction:	Staff stated that the fire marshal has been our recently, but has not sent the facility the report.
Standard #:	8VAC20-780-500-B
Description:	Based on observation, the facility failed to clean and sanitize the diaper changing table as required after each use. Evidence: Staff sprayed disinfectant on the diaper changing table and wiped with a paper towel. This surface was not allowed to air dry for a period of at least 1 minute (recommended air dry time for center's disinfectant).
Plan of Correction:	Per owner: Diapering process updated, please see attached. The teachers have been trained and reminded again to wait for 1 minute between the diaper changes and to use both sanitizer and soap & water in between diaper changes.
Standard #:	8VAC20-780-510-B
Description:	Based on review of eight medications for four children, the facility failed to have documentation of written parent authorization to administer one medication to one child. Evidence: the medication authorization form for Child A was signed by the physician, but was not signed by the parent.
Plan of Correction:	Written parental authorization has been obtained.
Standard #:	8VAC20-780-530-A-1
Description:	Based on staff interview and record review, the facility failed to have one staff in each grouping of children with cardiopulmonary resuscitation (CPR) that included an in person competency demonstration. Evidence: Staff 2 and Staff 6 were alone with children during rest time. The documentation of CPR training did not include an in person competency demonstration. Staff 6 stated that the training was online only.
Plan of Correction:	Friday (9/1), we have scheduled an in-person first aid/CPR for all staff. Anyone who does not have in-person CPR is required to attend.
Standard #:	8VAC20-780-550-E
Description:	Based on review of the emergency drill log and staff interview, the facility failed to conduct a shelter in place drill a minimum of twice per year. Evidence: there was documentation of only one shelter in place drill in the past year. Staff confirmed that a second shelter in place has not been conducted.
Plan of Correction:	A shelter in place drill has been conducted in the past week.
Standard #:	8VAC20-780-550-F
Description:	Based on review of the emergency drill log and staff interview, the facility failed to conduct a lockdown drill at least once annually. Evidence: there was no documentation of a lockdown drill. Staff confirmed that a lockdown has not been conducted.
Plan of Correction:	A lockdown drill was conducted in the past week.