VIRGINIA DEPARTMENT OF SOCIAL SERVICES

A Child's Place at Hollin Hall
1500 Shenandoah Road
Alexandria, VA 22308
(703) 765-8811

Current Inspector: Pamela Sneed (804) 629-2691

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

Technical Assistance:

1. Staff records and training records should be maintained in a manner that allows for verification of required documents. If kept off-site, the records are to be submitted within the agreed timeframe. 2. Construction supplies on the exterior of the building should be stored in a manner that prevents access by the children. Recommend the area of damaged asphalt be repaired, as it is in the path of travel to/from the playground.

Comments:

Conducted an unannounced inspection at 12:05pm (along with a simultaneous complaint investigation). Observed 75 children + 10 direct-care staff. Children were engaged in a variety of activities to include: story-time, handwashing, eating lunch, toileting, and outdoor active play. Staff were actively engaged with the children and activities. Lunch served: turkey burger, bread, cheese, pears and milk. The facility could benefit from a deep floor cleaning. Supplies and equipment were sufficient for the children. Areas of non-compliance with standards and laws reviewed were found. Questions about this inspection may be directed to pamela.sneed@doe.virginia.gov

Violations:

Standard #:	22.1-289.011-F
Description:	Based on observations made, staff did not ensure that the findings from the most recent inspection were posted in the facility. Evidence: The inspection report from 7/14/22 was posted.
Plan of Correction:	1. Inspection Report is posted.
Standard #:	22.1-289.035-B-4
Description:	Based on records reviewed, management failed to ensure that 2 of 2 staff records included an out-of-state central registry search within the 1st 30-days of employment. Evidence: 1. Staff #1 - Date of hire was in October 2021 and to-date there was not a completed out-of-state central registry search on-file. 2. Staff #6 - Date of hire was in June 2023 and to-date there was not a completed out-of-state central registry search on-file.
Plan of Correction:	1 & 2. Central Registry searches will be completed for any employee. The corporate office had the file for [name of Staff #6]. Another one was completed for [name of Staff #6] and {name of Staff #1] to ensure the whole file is completed and here on site.
Standard #:	8VAC20-770-60-B
Description:	Based on records reviewed, management did not ensure that 1 of 6 staff records included documentation of a completed sworn disclosure statement prior to the 1st day of employment. Evidence: 1. Staff #1-The sworn disclosure statement (SDS) signed and dated at the time of hire in 2021 did not include true information. Staff #1 indicated that there was no out-of-state residency in the previous 5 years however, according to the central registry search (CPS) dated 2022 the staff person had lived in Maryland in 2017.
Plan of Correction:	1. Sworn disclosure statement has been received from the corporate office and placed in employee's file. Also, staff member with error in states lived has filled out new documents. They live in MD in 2017 and background check will come back soon for this employee. This was for a document from 2022.
Standard #:	8VAC20-770-60-C-2
Description:	Repeat violation. Based on records reviewed, management failed to ensure that 1 of 6 staff records included documentation of a completed in-state central registry search within the 1st 30-days of employment. Evidence: Staff #6-The 1st day of employment was in June 2023 and to-date there was not a completed central registry search on-file.
Plan of Correction:	Central Registry searches will be completed for any employee. The corporate office had the file. Another one was completed to ensure the whole file is completed and here on site.
Standard #:	8VAC20-780-160-C
Description:	Based on records reviewed, management did not ensure that 1 of 6 staff records included documentation of a TB screening every 2 years. Evidence: Staff #5-The date of the last TB screening was 4/1/21.
Plan of Correction:	Employee [name of Staff #5] has scheduled a TB test 9/14/23 and will have results soon. Moving forward TB test due dates will be noted in outlook calendar with reminders before due date.
Standard #:	8VAC20-780-60-A
Description:	Based on records reviewed, staff failed to ensure that 1 of 3 children's records included required information. Evidence: Child #2- There was no documentation of the emergency medical authorization.
Plan of Correction:	1. Emergency medical authorization has been completed for [name of Child #2].
Standard #:	8VAC20-780-70
Description:	Based on records reviewed, management failed to ensure that 1 of 6 staff records include required documentation. Evidence: 1. Staff #4 - There was no documentation of the date when this staff person was promoted from Aide to Lead Teacher. The training certificate used to provide required training for the promotion was not signed by the trainer.
Plan of Correction:	1. Moving forward all staff will be brought in for a meeting on promotions. Moving forward all training certificates will be signed or have proof of completion from their respective organizations. [Name of Staff #4] is aware that she is a lead teacher.
Standard #:	8VAC20-780-90--A
Description:	Based on records reviewed, it was determined that 1 of 3 children's records did not include documentation of required immunizations. Evidence: Child #1 - The immunization record, signed by the physician, stated the child was to obtain additional immunizations after 12/25/22, though there was no documentation that these immunizations were obtained. The physican documented "CONDITIONAL ENROLLMENT: As specified in the Code of Virginia ? 22.1-271.2, B."
Plan of Correction:	1. Parents have been asked for copy of immunizations. They have been received we will have documents by close of business today. [sic]
Standard #:	8VAC20-780-240-A
Description:	Based on records reviewed, management did not ensure that 1 of 6 staff records included documentation of the Virginial Preservice Training class (10 hours) within the first 90-days of employment. Evidence: Staff #1-The 1st day of employment (most recent rehire) was 10/4/21 and to-date there was no documentation of the 10-hour training class being completed.
Plan of Correction:	1. Staff has been aske to produce training certificate by 9/18/2023 even if it means taking the class again. [sic]
Standard #:	8VAC20-780-245-A
Description:	Based on records reviewed, staff failed to ensure that 3 of 6 staff records included documentation of a minimum of 16 hours of annual training. Evidence: 1. Staff #2-There were 0 of 16 hours of annual training documented in the last year. The last training on-file was dated 2/7/21. 2. Staff #3-There were 12 hours of annual training documented since 12/16/21. 3. Staff #5-There were 3 hours of annual training documented since 12/17/21.
Plan of Correction:	1, 2,&3 new training schedule will be followed to ensure staff development and all required hours/trainings get done.
Standard #:	8VAC20-780-270-A
Description:	Based on observations made, staff failed to ensure that areas of the center were maintained in a clean and safe condition. Evidence: 1. The floor in the hall cot closet (for Preschool 2 class) was dirty with trash and flaking black paint. 2. The floor just inside the doors used to go to/from the playground was dirty with grass, dirt and trash. 3. Two rubber stair riser treads on the steps leading to the doors to go to/from the playground were torn/broken and missing. 4. Paper trash and discarded water bottles were observed on the playground. 5. Carpet/rugs in the Preschool-2 classroom were stained and dirty.
Plan of Correction:	1. Entire floor in the whole school was stripped and cleaned. Black Paint will be repaired when children are not present by 9/17/2023. 2. We will be aware of yard trimmings that come into the building especially on days when the grass has just been cut. Management and staff will monitor for any trash or debris in this area. 3. Rubber stair riser treads will be fixed by the county, this is a county building and that is a shared space. A work order has been submitted and follow up will continue until repair is done. 4. Playground inspects will happen in the morning when management arrives. Teachers and management will stay alert and notice if there are debris or trash. This trash will be discarded of right away. This is a county building and unfortunately the public does make a mess. We will make sure to do our part so ensure their messes are eliminated. We understand the importance of a clean environment for children. 5. The rugs and carpets in the whole building have been replaced or deep cleaned., We also purchased extra rugs to ensure that we are ready to replace any when necessary.
Standard #:	8VAC20-780-290-A-3
Description:	Repeat violation. Based on observations made, staff failed to ensure that all electrical outlets had protective covers. Evidence: An outlet in the Preschool-1 classroom, children ages 2-3 years old, did not have a protective safety cover.
Plan of Correction:	Multiple outlet covers have been purchased. Each classroom will have extras in their room. All staff will be required to inspect for this. We have cleaners that may remove them to vacuum and need to be aware that they might not get put back. Understand of working together on this is understood.
Standard #:	8VAC20-780-420-E-3
Description:	Based on records reviewed, staff failed to ensure that 2 of 3 children's records included documentation of the parents reviewing/signing that their child's information was up to date. Evidence: 1. Child #1 - Parents last signed the record 1/21/22. 2. Child #3 - Parents last signed the record 6/9/22.
Plan of Correction:	1. All parents have been given new enrollment form to sign or document to sign stating they have read enrollment for and all information is correct. [sic] This will ensure we have most recent contacts on file. Every September parents will be required to fill this form out to ensure it is current. New families will be required to fill out this form upon starting.
Standard #:	8VAC20-780-550-P
Description:	Based on records reviewed, management did not ensure that 5 of 5 written injury reports included required documentation. Evidence: 5 of 5 reports did not document the date, time and how the parent was notified of their child's injury.
Plan of Correction:	1. All staff have been guided on how to complete injury reports. Examples are hung on inside of closet doors. They must fill in all lines.