VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Monticello Area Community Action Agency-Louisa
302 West Main Street
Louisa, VA 23093
(434) 295-3171

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: Oct. 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 October 24, 2023. It was discussed that this location does not have a qualified program director or program leader. There were 15 children present, ranging in ages from 3 years to 4 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 5 child records and 2 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 #:	8VAC20-780-140-A
Description:	Based on a review of children?s records and interview, the center failed to obtain documentation of a physical examination by or under the direction of a physician for each child before the child's attendance or within one month after attendance. Evidence: The record of child #1, enrolled 08/09/2023, did not contain documentation of a physical examination. Staff #1 confirmed there was no physical in the record.
Plan of Correction:	Agency to ensure physical examination is on file before a student attends class or within one month after attending class.
Standard #:	8VAC20-780-40-E
Description:	Based on a review of records and staff interviews, 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. Evidence: 1. The medication policy in the family handbook was reviewed. On page 11 of the family handbook it states "If your child has a medical need or will require doses of any medication while in the classroom, the prescribed medication along with a signed Medication Authorization Form must be submitted to the Health & Wellness Manager before the first day of class or as soon as it has been prescribed. Your child will not be able to start class until the Health & Wellness Manager has received and discussed the submitted form with you." 2. An emergency medication (epi-pen) for child #6 was observed on-site. 3. There was no documentation of parent medication authorization on-site or in the child's record. 4. Staff #1 and staff #3 both confirmed the center did not obtain medication authorization from the parent.
Plan of Correction:	Agency will ensure required documentation is on file.
Standard #:	8VAC20-780-200-A
Description:	Based on review of documentation and interviews with staff, the facility failed to have a qualified program director or a qualified back-up program director who meets one of the director qualifications regularly on site at least 50% of the facility's hours of operation. Evidence: 1. At the time of inspection staff #1 and staff #2 were the only staff present. Both staff stated they are the only staff ever at this location. 2. The records of staff #1 and staff #2 did not contain documentation of program director qualifications. 3. Staff #3 confirmed this center does not have a qualified program director on-site at least 50% of the time.
Plan of Correction:	Agency to ensure a qualified program director or a qualified back-up director is on-site at least 50% of the facility's hours of operation.
Standard #:	8VAC20-780-340-D
Description:	Based on observation, record review and staff interviews, the licensee did not ensure that in each grouping of children there was at least one staff member who meets the qualifications of a program leader. Evidence: 1. At the time of inspection there were two staff at this location, staff #1 and staff 2. Both staff stated there is no program leader at this location. The records of staff #1 and staff #2 did not contain documentation of program lead qualifications. 3. Staff #3 confirmed there was no program leader at this location.
Plan of Correction:	Agency to scaffold staff through trainings to be qualified as program leader.
Standard #:	8VAC20-780-510-F
Description:	Based on a review of two medications and interview, the center failed to ensure the medication authorization for one medication was available to staff during the entire time they were effective. Evidence: 1. On October 19, 2023, one emergency medication was observed on-site for child #6. There was no documentation of medication authorization in the record or on-site for child #6. 2. Staff #1 and #3 confirmed there was no medication authorization for child #6.
Plan of Correction:	Agency will ensure required documentation is on file.
Standard #:	8VAC20-780-540-D
Description:	Based on observation and interview, the center failed to ensure the required emergency supplies are at the center and available on field trips. Evidence: There was no ice pack on-site. Staff #1 confirmed there was no ice pack.
Plan of Correction:	Agency will ensure required emergency supplies are at the center. Ice pack on-site.
Standard #:	8VAC20-780-550-F
Description:	Based on a review of the log for procedures for emergencies and interview, the center failed to ensure lockdown procedures are practiced at least annually.. Evidence: 1. There was no documentation of a lockdown drill being practiced in 2022. Staff #1 confirmed the lockdown drill was not completed.
Plan of Correction:	Agency will ensure lockdown drill is conducted annually.
Standard #:	8VAC20-780-550-P
Description:	Based on review of records and interview, the center did not ensure three of five written records of children's serious and minor injuries contained all the required information. Evidence: 1. Injury reports #1 and #2 contained one staff signature. The requirement is two staff signatures or one staff and one parent signature.
Plan of Correction:	Two staff signatures will be scribed on injury reports.