VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Culpeper United Methodist Church
1233 Oaklawn Drive
Culpeper, VA 22701
(540) 825-0764 (107)

VDSS Contact: Amy Tomblin (804) 629-3923

Inspection Date: May 6, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-191 Background Checks for Child Welfare Agencies 63.2 Child Abuse & Neglect 63.2(17) License & Registration Procedures

Comments:

An unannounced monitoring inspection was conducted on 5/6/19 from 10:20 am until 12:15 pm to review the religious exempt requirements. At the time of the inspection 37 children were present with five staff. The sample size consisted of five children's records and five staff's records. Children and staff were observed during free indoor and outdoor play, educational and artistic activities, hand washing, bathroom break, snack, pick-up, transitions, and behavioral guidance. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to me within five 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 preventive measure(s). If you have questions or concerns contact the licensing inspector at (540) 292-5933 for further assistance.

Violations:

Standard #:	22VAC40-191-40-D-2
Description:	Based on record review and interview, the center failed to ensure all staff completed a sworn disclosure statement prior to the first day of employment. Evidence: 1. The records for five staff were reviewed. The records for staff 1, start date 8/17, and staff 5, start date 8/22/19, did not contain a signed sworn disclosure statement. 2. The director verified they did not have a sworn disclosure statement for staff 1 and staff 5.
Plan of Correction:	Staff signed the sworn disclosure statement on 5/7/19. The director placed additional copies in the new hire forms packet and added it to the checklist of forms to be filled out for all new hires with a note to be completed prior to start date.
Standard #:	63.2(17)-1716-A-3-b
Description:	Based on observation and interview, the center failed to ensure the ratio of one staff to ten children ages twenty-four months to six years is maintained. Evidence: 1. Upon entering the right side of the three's classroom, three children were found in the classroom and one child was in the restroom. No staff member was in the classroom or restroom. The lead teacher was in the adjoining classroom with seven other children. The rooms are separated by a standard door sized cased opening. Approximately five minutes later the assistant teacher returned. 2. The lead teacher stated the assistant teacher is normally posted in the other classroom but she stepped out. 3. The director stated this is not normal practice and staff are not to leave children alone, however it was her understanding from the fire marshal the two classrooms are one since there is no door. 4. Upon entering the 4's classroom the teacher was alone with 12 children. 5. The director stated it is regular practice for one teacher to go to the adjoining room to prepare for the next activity during snack. The fours classroom has 16 children enrolled. This is also done in the 3's classroom which has 12 children enrolled. The director stated it was her understanding from the fire marshal that the two classrooms were considered one room because there is no door. 6. The 4's classroom has a short hallway at the back of the classroom with a sink and cabinets separating the two classrooms.
Plan of Correction:	The director held a staff meeting on 5/7/19 to discuss the inspection and the importance of proper supervision at all times. The director informed the staff that there must be one adult for every 10 children at all times and no children should ever be left unattended. The staff understood and assured the director that it would not happen again. The director will randomly check on classrooms to ensure proper supervision and within required ratios.
Standard #:	63.2(17)-1716-A-4
Description:	Based on record review, the center failed to ensure all staff obtained documentation from a physician that they are free from any disability which would prevent him/her from caring for children under his/her supervision by the first date of employment and annually thereafter. Evidence: 1. Five staff records were reviewed. The record for staff 5, start date 8/22/18 did not contain documentation of a staff health form. 2. The director stated staff 5 was not required to obtain a health form.
Plan of Correction:	The director gave staff member the health report to have completed ASAP. The staff member returned completed form on 5/9/19. The director will ensure each staff member has a staff health report on file annually.
Standard #:	63.2(17)-1716-B-3
Description:	Based on interview, the center failed to establish and implement a procedure in which daily simple health screening and exclusion of sick children is completed daily by a person trained to perform such screenings. Evidence: The director stated they have a procedure for daily simple health screening and exclusion of sick children but not by a person trained to perform such screenings.
Plan of Correction:	The director has looked up and gotten the information for the health screening for child care professionals (CHLD2016). She will complete this training during the week of 5/13/19. The director will then train her staff in Daily Health Screening and ensure this is done on a daily basis. The training certificate will be forwarded to the inspector at time of completion.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on record review and interview, the center failed to ensure staff hired after 1/22/18 had a fingerprint-based criminal history check determination letter prior to the first day of employment. Evidence: 1. Five staff records were reviewed. The record of staff 5, start date 8/22/19, contained a fingerprint background check dated 8/30/19. 2. The director confirmed the dates.
Plan of Correction:	The director placed notes in the new hire form packet and on the checklist of forms for new hires that finger prints must be returned prior to the first day of work. The director will ensure this is completed for all new hires.