VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Epiphany Lutheran Church of Mount Vernon
5521 Old Mill Road
Epiphany Weekday School
Alexandria, VA 22309
(703) 780-3852

VDSS Contact: Kara Vaughan (703) 537-6241

Inspection Date: April 23, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-191 Background Checks for Child Welfare Agencies 54.1-3408 Must be MAT Certified. 32.1 Report by person other than physician 63.2 Child Abuse & Neglect 63.2(17) License & Registration Procedures 63.2 Facilities & Programs. 22VAC40-665 INTRODUCTION 22VAC40-665 ADMINISTRATION 22VAC40-665 STAFF QUALIFICATIONS & TRAINING 22VAC40-665 PHYSICAL PLANT 22VAC40-665 STAFFING & SUPERVISION 22VAC40-665 PROGAMS 22VAC40-665 SPECIAL CARE PROVISIONS & EMERGENCIES 22VAC40-665 SPECIAL SERVICES

Technical Assistance:

1. Reviewed background check requirements and timelines.

Comments:

10:15am-12:45pm Conducted an unannounced religious exempt program inspection. Observed 34 children + 8 direct-care staff. Ratios and supervision were in compliance. Children were engaged in a variety of activities, to include: outdoor active play, eating snack, reading books, and small group literature/reading program. Staff were actively engaged with the children and activities. The facility was found to be very clean and well maintained, safeguarded appropriately, and well supplied with toys and equipment for the children. The outdoor playground and music/art garden areas were well maintained, and offer outdoor play/classroom space. Staff are currently trained in First Aid, CPR. and MAT (medication administration). Administrative and background check violations found.

Violations:

Standard #:	22VAC40-191-40-C-2
Description:	Based on records reviewed and interview conducted, it was determined that 4 of 10 staff records did not include a signed sworn disclosure statement (SDS) prior to the first day of employment. Evidence: (1) Staff #3-hired January 2019. (2) Staff #-hired December 2018. (3) Staff #5-hired August 2018. (4) Staff #8-hired August 2018. (5) The Director stated that they were not completed because of inaccurate information or a misunderstanding of communications received from VDSS. Based on records reviewed and interview conducted, it was determined that 10 of 10 staff records did not include a completed central registry check (CPS) by 7/1/18, or within the first 30 days of employment. Evidence: (1) Staff #1, Staff #2, Staff #3, Staff #4, Staff #5, Staff #6, Staff #7, Staff #8, Staff #10, and Staff #11. (2) The Director stated that they were not completed because of inaccurate information or a misunderstanding of communications received from VDSS.
Plan of Correction:	All staff will complete a SDS within 10 days, by 5/3/19. All staff will submit a CPS check within 10 days, by 5/3/19.
Standard #:	63.2(17)-1716-A
Description:	Based on records reviewed and interview conducted, it was determined that required information was not disclosed in writing to parents and guardians. Evidence: (1) Exemption from licensure. (2) Qualifications of personnel. (3) The Director stated that this information is currently provided verbally, not in writing.
Plan of Correction:	These items will be added to the parent handbook for the fall program.
Standard #:	63.2(17)-1716-A-6
Description:	Based on records reviewed and interview conducted, it was determined that required information was not disclosed to parents, guardians, and the general public. Evidence: (1) (Physical facilities. (2) Enrollment capacity. (3) Health requirements for staff. (4) Public liability insurance.
Plan of Correction:	These items will be added to the parent handbook for the fall program.
Standard #:	63.2(17)-1716-B-3
Description:	Based on interview conducted, it was determined that staff have not completed daily health screening training. Evidence: The Director stated that they do a daily health screening of children each day, but have not completed a formal training.
Plan of Correction:	Staff will complete daily health screening training before the fall program begins.