VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Right at School at John Kerr Elementary
427 Meadow Branch Avenue
Winchester, VA 22601
(540) 583-8148

Current Inspector: Barbara Workman (540) 430-9257

Inspection Date: Nov. 13, 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 63.2 Child Abuse & Neglect

Comments:

A non-mandated inspection was conducted on November 13, 2023 from 3:25 P.M.-5:15 P.M. There were 11 children present, ranging in ages from five to ten years of age, with two 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 five child records and two 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. If you have any questions or concerns please contact the Licensing Inspector at 540-430-9257.

Violations:

Standard #:	22.1-289.011-F
Description:	Based on observation, the center failed to ensure that the finding of the most recent inspection were posted. Evidence: The finding of the most recent inspection, (08/09/2023), that were emailed to administration on 08/11/2023 were not posted.
Plan of Correction:	All inspection notices are now posted and will be reviewed by the program manager and area manager on a monthly basis.
Standard #:	22.1-289.035-B-4
Description:	Based on a review of staff records, the facility failed to obtain out-of-state background checks on individuals who have resided outside of Virginia within the past five years. Evidence: 1. Staff #1 indicated on a sworn disclosure statement dated 07/21/2023 that they had lived in one other state within the past five years. 2. Staff #1's date of hire was 08/10/2023 there was not a record of the out-of-state sex offender name check completed prior to hire and there was not a record of an out-of-state child abuse and neglect check sent out by the 30th day of hire. 3. Staff #2's indicated on a sworn disclosure statement dated 07/07/2023 that they had lived in one another state within the past five years. 4. Staff #2's date of hire was 08/10/2023 there was not a record of the out-of-state sex offender name check completed prior to hire, and there was not a record of an out-of-state child abuse and neglect check sent out by the 30th day of hire. 5. Staff #3 verified that the out-of-state background checks were not completed in the correct timeframe.
Plan of Correction:	An in-depth review of all records is being conducted by the Program Manager and will be updated before 11/22/2023. All records will be completed upon hiring in the future.
Standard #:	8VAC20-780-140-A
Description:	Based on review of children records, the center failed to ensure that a physical examination was in the record within 30 days after the first date of attendance. Evidence: 1. Child #2's date of enrollment was 08/10/2023. There was not documentation of a physical examination in the record. 2. Staff #3 verified that here was not a physical in the record.
Plan of Correction:	Complete children's records will be completed by 11/22/2023. All children enrolling in the program in the future will have completed records prior to beginning the program.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of children records, the center failed to ensure that all required information was contained in the children's records. Evidence: 1. Child #1 and Child #2's record only contained one of the two designated people to call in an emergency if the parent cannot be reached. 2. Child #1 and Child #3's record did not contain the date of enrollment.
Plan of Correction:	All emergency contacts will be updated before 12/1/23 or children will not be allowed to return to the program. Future enrollments will have paperwork reviewed and corrected prior to the first date of enrollment.
Standard #:	8VAC20-780-70
Description:	Based on a review of staff records, the center failed to ensure that all required information was in staff records. Evidence: 1. Staff #1's date of hire was 08/10/2023. The record only contained one of the two required reference checks as to character and reputation, as well as competency that are required prior to the date of employment. 2. Staff #2's date of hire was 08/10/2023. The reference letters in the record were dated 08/21/2023 and 11/01/2023. References are required to be obtained prior to the date of employment.
Plan of Correction:	All reference letters will be added to existing employee files. Future employees mut provide them before starting employment.
Standard #:	8VAC20-780-240-A
Description:	Based on review of staff records, the center failed to ensure that the Virginia Department of Education sponsored orientation course shall be completed within 90 calendar days of employment. Evidence: 1. Staff #1's date of hire was 08/10/2023. There was not documentation in the record that the training had been completed. The training was required to be completed by 11/10/2023. 2. Staff #1 verified that the training had not been completed.
Plan of Correction:	All employees that are hired from this point on will be made to complete all on-boarding prior to start date.
Standard #:	8VAC20-780-245-L
Description:	Based on review of staff records and interview, the center failed to ensure that there was at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children. Evidence: 1. There was no documentation in the records for Staff #1 or Staff #2 of the Daily Health Observation training being completed. 2. Staff #1 and #3 verified that there was no staff member on duty that had completed the training.
Plan of Correction:	Staff will complete the training and all future employees will be taking the course before they begin work.
Standard #:	8VAC20-780-550-D
Description:	Based on a document review, the center failed to implement monthly practice evacuation drills. Evidence: 1. The program opened in 08/2023. There was no documentation that evacuation drills had been completed for 08/2023, 09/2023, and 10/2023. 2. Staff #1 verified that the evacuation drills had not been implemented.
Plan of Correction:	Area Manager is not scheduling the drills and sending out calendar invites to ensure they are done in a timely manner.