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: Oct. 6, 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

Comments:

An unannounced renewal inspection was conducted on 10/06/2023 from approximately 10:37 a.m. ? 5:55 p.m. There were 69 children present 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. A total of 12 child records and 8 staff records were reviewed. The information gathered during the inspection determined violations with applicable standards or law. A violation notice was issued. Please sign, 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 preventive measure(s). If you have any questions related to this inspection, please contact Susan Ellington-Sconiers, Licensing Inspector at 804-588-2368 or susan.ellington-sconiers@doe.virginia.gov.

Violations:

Standard #:	22.1-289.035-A
Description:	Based on staff record review, the provider failed to ensure that one of eight employees underwent background checks every five years. Evidence: The record for S8, contains searches of the central registry dated 08/30/2017 and 11/21/2022 and searches of the criminal history dated 04/11/2018 and 07/03/2023.
Plan of Correction:	The current director will make sure background checks are completed before the 5-year date. Employee files will be checked monthly. This has already been corrected and the new practice will be put in place immediately.
Standard #:	22.1-289.035-B-4
Description:	Based on staff record review, the provider failed to obtain the results of the out-of-state sex offender registry check and out-of-state child abuse and neglect search for each staff as required. Evidence: S3 documented on the sworn disclosure statement having lived out-of-state in the last five years. Record for S3, employed 06/01/2023 did not contain an out-of-state sex offender registry check prior to the 1st day of employment. The record for S3, employed 06/01/2023 did not contain results for an out-of-state child abuse and neglect search.
Plan of Correction:	The out-of-state sex registry and out-of-state child abuse and neglect backgrounds were searched in March 2023 by another childcare center. The individual hasn?t lived out of state since 2020. The out-of-state background reports were assumed to be portable since the employee transferred from one VDOE childcare center immediately to the current school. Going forward, the background check will be done by our school administration team for employees who lived out-of-state in the past 5 years prior to employment with our school. The director and assistant director will both go through new hire files to make sure background checks out-of-state are completed. This new protocol has already been put in place.
Standard #:	8VAC20-770-60-B
Description:	Based on record review, the provider failed to ensure an employee not be employed until the center has the person?s completed sworn statement. Evidence: The record for S2, employed 09/18/2023 documented a sworn statement dated 09/19/2023. The record for S6, employed 09/11/2023 documented a sworn statement dated 09/12/2023.
Plan of Correction:	The director will make sure all new hires and employees who renew their sworn statement put the correct date with their signature. It will be completed on the first day of hire or before. The director will verify this information is completed on or before the start date. This was put in place immediately.
Standard #:	8VAC20-780-140-A
Description:	Based on child record review, the provider failed to ensure that one of seven children had physical examination prior to attendance. Evidence: C1, enrolled 09/05/2023 did not have a physical examination in the child?s record.
Plan of Correction:	The school will make sure all physical examinations are completed in the required time. Children?s files will be reviewed by both the assistant director and director prior to a child starting at our school. The student files will also be monitored by the assistant director or the director monthly to make sure physicals and immunizations are updated timely. This practice has already been put into place.
Standard #:	8VAC20-780-140-B
Description:	Repeat violation Based on child record review, the provider failed to ensure that one of seven children had physical examination prior to attendance and within the prescribed time period. Evidence: C4, enrolled 09/05/2023, at 17 months, did not have a physical examination within the required three months prior to attendance. The physical examination was conducted 12/09/2022.
Plan of Correction:	The school will make sure all physical examinations are completed in the required time. Children?s files will be reviewed by both the assistant director and director prior to a child starting at our school. The student files will also be monitored by the assistant director or the director monthly to make sure physicals and immunizations are updated timely. This practice has already been put into place.
Standard #:	8VAC20-780-150-B
Description:	Based on child record review, the provider failed to ensure that one of seven immunizations records for children were signed by a physician, designee, or official of a local health department. Evidence: The immunization record for C1, enrolled 09/05/2023 was not signed by a physician, designee, or official of a local health department.
Plan of Correction:	The school will make sure all physical examinations are completed in the required time. Children?s files will be reviewed by both the assistant director and director prior to a child starting at our school. The student files will also be monitored by the assistant director or the director monthly to make sure physicals and immunizations are updated timely and have doctor?s signature on immunizations. This practice has already been put into place.
Standard #:	8VAC20-780-70
Description:	Based on staff record review, the provider failed to ensure that five of eight records contained required information. Evidence: Records for S1, employed 08/14/2023, S2, employed 09/18/2023, S3, employed 06/01/2023, S4 employed 08/07/2023, and S6, employed 09/11/2023 did not contain information about any health problems that may interfere with filling the job responsibilities.
Plan of Correction:	A form was signed by all employees the following week and placed in each person?s file stating they did not have a any health problems that may interfere with filling the job responsibilities. The director will make sure a form is signed stating there are no health problems that may interfere with their job on the first day. This is currently done through out corporate office prior to hiring. This will be kept on-site going forward. This has already been corrected.
Standard #:	8VAC20-780-510-B
Description:	Based on observation, the center administered a medication without written authorization from the parent. Evidence: A medication administration record (MAR) for C12 documented administration of a medication on 09/14/2023 and 9/15/2023. Center staff were unable to locate the written authorization from the parent.
Plan of Correction:	The medication authorization was signed prior to the medication being given to the child. The form and medication were sent home with the parent after the time it was to be administered. The school will keep a copy of all medication authorizations going forward. This new practice is already in place and will be monitored regularly by the assistant director and the director.
Standard #:	8VAC20-780-510-P
Description:	Based on review of children?s medications, the provider failed to ensure that when authorizations for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization or medications disposed of by the center. Evidence: Medications were observed in the center?s medication box for C8 and the parental permission ended 05/26/2023 and for C10 the parental permission ended 07/1/2023.
Plan of Correction:	The medications were given to the families or disposed of immediately. The assistant director and director will monitor the medication box regularly to make sure all medications are sent back to the families within 14 days of the authorization date. This was corrected immediately.