VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Family Community Church
120 Chestnut Drive
Culpeper, VA 22701
(540) 825-6420

VDSS Contact: Amy Tomblin (804) 629-3923

Inspection Date: Sept. 3, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-191 Background Checks for Child Welfare Agencies 54.1-3408 Must be MAT Certified. 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

Comments:

An unannounced subsidy health and safety monitoring inspection was conducted on 9/3/19 at Family Community Church from 11:00 am until 1:30 pm. At the time of the inspection 29 children were present with seven staff. The sample size consisted of five children's records and five staffs' records. Children and staff were observed during free indoor play, lunch, hand washing, pick-up, nap, transitions and behavioral management. Violations were found during this inspection and are documented on the violation notice. If you have questions or concerns contact the licensing inspector at (540) 292-5933 for further assistance.

Violations:

Standard #:	22VAC40-665-540-B
Description:	Based on record review and interview, the vendor failed to ensure all staff obtained updated TB screenings at least every two years from the date of the initial screening. Evidence: 1. The records of five staff were reviewed. Staff 1, 2 and 3 have documentation of the most current TB dated 1/30/17. Staff 4 has documentation of the most current TB dated 2/1/17. 2. The director stated she was unaware TB screenings had to be updated every two years.
Plan of Correction:	A system will be put in place to ensure all staff TB screenings are updated every two years.
Standard #:	22VAC40-665-640
Description:	Based on observation, the vendor failed to ensure all areas of the premises accessible to children are free from obvious injury hazards and cushioning material under the playground equipment is provided and maintained. Evidence: 1. The wood picnic table is located directly beside a slide and is splintering with peeling paint. 2. The swings on the outside of the fence do not have cushioning material under them.
Plan of Correction:	The picnic table will be removed from the playground and children will not be allowed to use the table. Children will not be allowed to use the swings until cushioning material is purchased.
Standard #:	22VAC40-665-650-E
Description:	Based on interview, the vendor failed to develop and implement a written policy and procedure that describes how the vendor will ensure that each group of children receives care by consistent staff or team of staff members. (Effective 10/17/18) Evidence: The director stated they do not have a consistency of staff policy.
Plan of Correction:	A consistency of staff policy will be developed and staff will be trained on the new policy.
Standard #:	22VAC40-665-700-C
Description:	Based on record review, the vendor failed to maintain a written record of each child's serious and minor injuries in which entries are made the day of occurrence and include the following: date and time of injury, name of injured child, type and circumstance of injury, staff present and treatment given, date and time parent was notified and staff and parent signature or two staff signatures. Evidence: Five injury reports were reviewed. Four did not have documentation of how and when parents were notified. Two only contained one signature.
Plan of Correction:	All staff will be retrained to correctly complete an injury report. Injury reports will be turned in to the director who will review the report for any errors.
Standard #:	22VAC40-665-770-B-5
Description:	Based on interview, the vendor failed to update the emergency preparedness plan to include a procedure regarding continuity of operations that ensures that essential functions are maintained during an emergency. (Effective 10/17/18). Evidence: The director stated they have not updated the emergency preparedness plan to include this procedure.
Plan of Correction:	A procedure regarding continuity of operations will be added to the emergency preparedness plan. All staff will be trained in the new procedure.
Standard #:	22VAC40-665-780-B
Description:	Based on record review and interview, the vendor failed to maintain a record of the dates of the shelter-in-place practice drills. Evidence: 1. A review of the practice drills conducted in 2018 was completed. No documentation of shelter-in-place drills was found. 2. The director stated they completed two shelter-in-place practice drills in 2018 but they weren't documented.
Plan of Correction:	All practice drills will be documented from now on.