VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Charlottesville Waldorf School
120 Waldorf School Road
Charlottesville, VA 22901
(434) 973-4946

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: April 9, 2024

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

Technical Assistance:

8VAC20-780-70 8VAC20-780-500A 8VAC20-780-550E 8VAC20-780-550G

Comments:

An unannounced renewal inspection was conducted on-site April 9, 2024 from 11:43am until 2:08pm. The director was available during the inspection. There were 32 children present, ranging in ages from 2 years to 5 years, with 7 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 5 staff records were reviewed. This inspection was amended on April 24, 2024 to include background checks of officers of the board not previously submitted. 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 #:	22.1-289.036-B-2
Description:	Based on a review of records and interview, the center failed to obtain a fingerprint based national criminal record check within 30 days of appointment of an officer of the board. Evidence: 1. The record of officer #3, took office 10/6/2022, contained documentation of fingerprints dated 4/7/2023. 2. The record of officer #5, took office 10/6/2022, did not contain documentation of fingerprints. 3. Staff #1 confirmed there were no results of fingerprints for officer #5.
Plan of Correction:	The Board secretary will use a checklist for onboarding new board members and they will not be added as a member until they submit all necessary paperwork. In addition, files will be kept electronically because Officer #3 already completed her full background check process but her file was lost when the business office changed location.
Standard #:	8VAC20-770-40-D-1-a
Description:	Based on a review of records and interview, the center failed to obtain a Sworn Statement and a central registry check from each officer of the board, when a change occurred, before the end of the 30 days after the change of officer. Evidence: 1. The record of officer #3, took office 10/6/2022, contained documentation of a sworn statement dated 04/12/2023 and did not contain documentation of a central registry check. Staff #1 confirmed the center did not have the central registry check. 2. The record of officer #5, took office 10/6/2022, contained documentation of a sworn statement dated 04/19/2024 and did not contain documentation of a central registry check. Staff #1 confirmed the center did not have the central registry check.
Plan of Correction:	The Board secretary will use a checklist for onboarding new board members and they will not be added as a member until they submit all necessary paperwork. In addition, files will be kept electronically because Officer #3 already completed her full background check process but her file was lost when the business office changed location.
Standard #:	8VAC20-780-40-M
Description:	Based on observation and interview, the center failed to maintain the current written list of children's allergies, sensitivities and dietary restrictions in a confidential manner. Evidence: In the Marigold classroom, the list of children's allergies was posted in open view in the classroom. Administration confirmed the list is posted in open view in that classroom and in the main office.
Plan of Correction:	We compiled the list of allergies and distributed to all classrooms.
Standard #:	8VAC20-780-60-A
Description:	Repeat Violation Based on a review of children's records and interview, the center failed to ensure that each child's record contained the required information. Evidence: 1. The record of child #1 did not contain documentation of address for two emergency contacts. 2. The record of child #4 did not contain documentation of the name, address, and phone number of a second person to contact in an emergency. 3. The records of child #1, child #2, and child #3 contain documentation of place of employment for parents but do not contain documentation of the work phone number. 4. Administration confirmed the information was missing.
Plan of Correction:	Admin assistant is following up with families for this information.
Standard #:	8VAC20-780-245-A
Description:	Based on a review of staff records and interview, the center failed to obtain an annual minimum of 16 hours of training appropriate to the age of children in care for each staff. Evidence: The record of staff #5 contained documentation of 4.5 hours of training from September 1, 2022 to August 31, 2023. Staff #5 confirmed the hours were not complete.
Plan of Correction:	Documentation of training will be held in our S.I.S. moving forward sing the implementation of our most recent IPOC. System change already implemented follow up on outstanding training will be done.
Standard #:	8VAC20-780-280-B
Description:	Based on observation, the center failed to ensure that hazardous substances were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. In the bathroom of the Rosebud classroom there was unlocked Isopropyl Alcohol on an open shelf. The label stated "keep out of reach of children" and "warning." 2. In an unlocked closet in the Rosebud classroom there was bleach water, 2 gallons of paint, and several cleaners, that could be accessed by children. The labels on the cleaners stated "keep out of reach of children" and "caution."
Plan of Correction:	Storing of hazardous materials will be discussed during weekly staff meeting.
Standard #:	8VAC20-780-510-H
Description:	Based on observation, the center failed to ensure nonprescription medication is in the original container with the direction label attached. Evidence: There were several tablets of Benedryl in the Marigold classroom. The Benedryl was not in the original container with the direction label attached.
Plan of Correction:	The Marigold classroom has been issued a new lockbook which includes medication administration guidelines to avoid future issues.
Standard #:	8VAC20-780-510-I
Description:	Based on observation and interview, the center failed to ensure that prescription medicine is maintained in the original, labeled container and the label on the medication identifies the child's name, prescriber's instructions pertaining to dosage, frequency, and manner of administration. Evidence: 1. In the Marigold classroom there were four Epi-pens that were not in the original container with a label on the medication that identifies the child's name, prescriber's instructions, dosage, frequency, and manner of administration. Staff confirmed they did not have the original container with label.
Plan of Correction:	The Marigold classroom has been issued a new lockbook which includes medication administration guidelines to avoid future issues.
Standard #:	8VAC20-780-510-L
Description:	Repeat Violation Based on observation, the center failed to ensure that medication is kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. There were two Epi-pens in an unlocked cabinet in the Marigold classroom. 2. There were several tablets of Benedryl in an unlocked cabinet in the Marigold classroom.
Plan of Correction:	Lockbox has been issued.