VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Country Day Care
2312 Dickens Road
Richmond, VA 23230
(804) 282-8502

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: Sept. 7, 2023

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs.

Comments:

An unannounced inspection was initiated on 9/7/2023 with a local agency in response to a self-report that was received by the licensing department on 9/1/2023 regarding allegations in the areas of supervision and operational responsibilities. The inspection was initiated on 9/7/2023 and completed on 10/17/2023. On 9/7/2023, the inspector was on site from approximately 3:00 pm-5:00 pm. Interviews with staff were completed, observations were made in the center, and documentation was reviewed. The inspector was on site on 9/11/2023 from approximately 9:00 am-9:30 am to conduct an interview. Additional interviews were conducted on 9/15/2023 and 10/12/2023. The preponderance of the evidence gathered during the investigation supports the allegation; therefore, the self-report is determined to be valid. Additional violations were found in the areas of attendance reports and children?s records. See the violation notice for more details. If you have any questions about this inspection, please contact the licensing inspector at (540) 430-0384. 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. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must 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 #:	8VAC20-780-40-E
Description:	Based on review of documentation and interview, the center did not ensure that their activities and services were maintained in compliance with the center's own policies and procedures that are required by these standards. Evidence: 1. The center?s playground safety procedure states that ?All staff members are to distribute themselves in an appropriate manner, evenly throughout the playground, so that all children may be seen at all times. If there is more than one classroom outside, remember that you are responsible for the direct supervision of all children and not simply for the class you lead.? Staff #1 acknowledged that she lost sight of child #1 sometime in between lining up and coming inside. Staff #2 stated that she did not see child #1 after staff #1?s class departed to go inside the building. 2. Administration acknowledged that the staff did not follow the safety procedures for active supervision that are required by the standards.
Plan of Correction:	Numerous adjustments have been made, both to the physical plant as well as to facility policies and protocols in place, to ensure these circumstances never transpire again. New six-foot fencing has been installed around the playground area along with closed circuit and live feed cameras. New fencing has also been used to divide the main portion of the playground, so the preschool and pre-k classrooms can utilize the front section, while the school age students have the back portion of the playground. All classes will have designated outside times and will no longer occupy the same space simultaneously on the playground to ensure ratios are kept based upon age group and all children are accounted for in attendance that day. No less than two staff members will always be present on the playground but can be in different sections when ratios permit. Prior to exiting the building onto the playground, a member of the management team will count all children with the supervising teachers. Upon re-entry to the building, management will meet the class at the door for another headcount. Also, starting Monday, November 6, 2023, we will be implementing the use of Procare?s ?Name to Face? option, which will allow staff to check students in and out for outdoor time and provide the opportunity for headcounts at various points throughout the day, including but not limited to recess. Staff will participate in a mandated training during a staff meeting on Thursday, November 2, 2023, to learn how to use this feature, and Friday, November 3, 2023, will be used as a ?trial run? day to work out any issues and address staff questions and concerns in regard to the implementation of this system. Lastly, all staff will be required to have a cell phone on their person when outdoors in case of an emergency requiring additional assistance.
Standard #:	8VAC20-780-60-A
Description:	REPEAT VIOLATION Based on records review and interview, the center did not ensure that one child?s record contained the required information. Evidence: 1. The record of child #1 (date of enrollment: 3/6/2023) did not contain a second complete emergency contact. Children?s records are required to contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. 2. Administration acknowledged the emergency contact information was incomplete.
Plan of Correction:	Maintaining appropriate documentation is a critical component of compliance with licensing guidelines. Due to this violation being a repeat offense, stringent policies and protocols will take effect to ensure this issue does not transpire again. Any future enrolling families will need to have their child registered and required documents will need to be given to management no less than five business days prior to the students? start date. This gives management the opportunity to review all documents and contact the family if there are any missing components. During the annual re-registration process, which transpires at the beginning of each school year, families will be given thirty days to provide all necessary, current documentation to management. They will receive a reminder two weeks prior to the due date as well. If a family does not provide the necessary documentation for their child?s file, services will be suspended until that information is provided. Due to the recurrence of this issue, all current student files will be reviewed by the Regional Director during the month of November 2023.
Standard #:	8VAC20-780-80-A
Description:	Based on a review of records and interview, the center did not ensure to maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurred. Evidence: 1. Upon review of attendance records from 9/1/2023, staff stated that several children were signed out over an hour after departure. 2. Administration acknowledged that there were times when children were not signed out immediately as they departed for the day.
Plan of Correction:	When the facility transitioned from daily paper documentation to the utilization of Procare, management took on the responsibility of ensuring each student would be signed in upon arrival and signed out upon departure via the Procare application. However, this system has proven to be inefficient, so to ensure every child is signed in and out at the appropriate time based upon arrival and departure, teachers from each class will be responsible for digitally documenting the attendance of each student in their care. When a child arrives, the teacher will manually sign that student into his or her designated class; when a child leaves for the day, he or she will be manually signed out by the supervising teacher at that time. The transition of this responsibility from management to staff will be reviewed and discussed at the mandated meeting and training transpiring Thursday, November 2, 2023. The training will cover the steps necessary for this procedure, and the Regional Director will oversee this transition as well. To maintain paper documentation of daily attendance including arrival and departure times for each child, a member of management will print out the month?s attendance from Procare and keep it in a binder in the main office.
Standard #:	8VAC20-780-340-A
Description:	Based on a review of documentation and interview, the center did not ensure that when staff are supervising children; they always ensured their care and protection. Evidence: 1. On 9/1/2023, the department received a self-report that child #1 (age four) had left the premises of the center and was located near the road in the front of the building. In interview, teacher #1 stated that she was supervising approximately 18 children ranging in age from two years to five years with teacher #2. Teacher #1 stated that she took her group of children inside at approximately 4:20 pm. Once inside, she observed that child #1 was missing but that pickup time was chaotic, and it took her awhile to notify administration. At approximately 4:45 pm, staff #3 saw child #1 across the street from the center with witness #1, an adult female. Staff #3 stated that she attempted to call the director. Around the same time, witness #2, an unidentified adult male, arrived at the center to ask if child #1 belonged in their care. Staff #4 left the center to retrieve the child. At this time, local law enforcement had arrived based on a report from witness #1 who said that child #1 had been located on Dickens Road. In an interview, witness #1 stated that she stopped her car when she saw a car stopped in the middle of the road. The driver of the car was holding the wrist of a child through the window and calling for help. Witness #1 got out of her car and picked up the child. She said that the driver informed her that she almost hit the child with her car and was holding him so no one else struck him with their vehicle. She said they were approximately a half a block away from the center. The speed limit on the road is 35 MPH and traffic runs in both directions. Staff stated that when child #1 returned he was red in the face and thirsty. Child #1 is non-verbal and could not communicate the events that took place. 2. In interview, staff stated that they believed that child #1 had climbed over the center?s chain linked fence because he had attempted to climb over the fence multiple times. Staff stated that each time, a staff member had to guide him off fence. Staff #1 stated that she had seen child #1 get completely over the fence before being stopped. Staff stated that management was made aware of the situation.
Plan of Correction:	The health and safety of children within our learning community is our top priority. The adjustments made to the physical plant include a new consolidated six-foot fence to remove blind spots and create a more significant barrier between the playground and the area beyond it as well as new closed circuit, live feed cameras that management can see in real time. New outdoor policies and protocols work to prevent the opportunity for any child in our care to no longer be outside of sight and sound supervision of staff and include the implementation of these concepts: a simultaneous headcount by both a member of management as well as the supervising staff prior to exiting the building and at re-entry, providing each age group with separate designated outside times, ensuring no less than two staff members are out on the playground when any class is outside, creating multiple areas for use on the playground based upon age group, and implementing the use of Procare?s ?Name to Face? option to use during the headcount process for ensuring that each and every individual child is accounted for in attendance that day. Once again, a review of current new outdoor policies and protocols will transpire on Thursday, November 2, 2023, and it is mandated that all staff attend. Friday, November 3, 2023, will give both management and staff the opportunity for a trial run while under the guidance and supervision of the Regional Director prior to full implementation starting Monday, November 6, 2023. Staff are required to communicate with management as well as document in writing any incident or episode where a child?s safety is potentially compromised by their actions. In turn, management is required to report these circumstances to the Regional Director immediately, so a plan can be implemented to ensure the safety of that child.
Standard #:	8VAC20-780-340-F
Description:	Based on a review of documentation and interview, the center did not ensure that children under 10 years of age were always within actual sight and sound supervision of staff. Evidence: 1. On 9/1/2023, child #1, age 4, was determined to be out of the sight and sound of staff for approximately 25 minutes. During that time, child #1 left the premises of the center and was located on a busy street by several witnesses. Local law enforcement was called to assess the situation and approve the transfer of care from witness #1 to the center. 2. Administration acknowledged that child #1 was not within actual sight and sound supervision of staff.
Plan of Correction:	The perimeter of the new six-foot fence has been consolidated to remove any blind spots from the area. Staff will review both existing and updated outdoor policies and protocols and discuss the implementation of the new system along with the reasoning behind it at the mandatory meeting on November 2, 2023, and will sign off on those expectations accordingly. Furthermore, a review of the importance of both sight and sound supervision will be conducted at this meeting to ensure all staff are aware of both company and licensing expectations.
Standard #:	8VAC20-780-350-C
Description:	Based on interviews, the center did not ensure that when children are in ongoing mixed age groups, the staff-to-children ratio and group size applicable to the youngest child in the group applied to the entire group. Evidence: 1. In interviews, two staff stated that the two-year old class often combined with preschool aged children on the playground in the afternoon. Staff acknowledged that when combined on numerous occasions, including the afternoon of the incident 9/1/2023, they exceeded the required two-year old ratio of one staff to eight children (1:8). Staff stated that there were occasions where they had two staff and over 20 children, ranging in age from two years to five years.
Plan of Correction:	Moving forward, each designated area of the playground will only have one class utilizing that space at a time to ensure ratios are maintained for each age group. Furthermore, classes will only be permitted to have children of mixed age ranges at the beginning and end of the day when student numbers are at their lowest and only when the ratio of the youngest child can be maintained. Lastly, mixing age groups of children will only be permitted inside the building and never during outdoor activities, including but not limited to recess.