VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carol Godfrey
1835 Silver Star Lane
Culpeper, VA 22701
(540) 522-4588

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: March 2, 2023

Complaint Related: No

Areas Reviewed:

8VAC20-790 Subsidy Regulations.

Comments:

An annual subsidy health and safety (SHSI) inspection was conducted on March 2, 2023 from 10:30 A.M.-12:30 P.M. There were three children present for a total of nine points with one caregiver supervising. Areas reviewed during the inspection included physical plant, diapering, safe sleep, emergency preparedness planning, evacuation drills, required postings, first aid supplies and non-medical emergency supplies, three children records, one caregiver records, and two pet vaccinations 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 #:	8VAC20-790-170-C
Description:	Based on a review of caregiver records, the provider failed to obtain updated background checks every five years. Evidence: 1. Caregiver #1?s sworn disclosure statement on file was dated 02/19/2018. 2. Caregiver #1 verified that an updated sworn disclosure statement had not been completed.
Plan of Correction:	Will track when background checks are in need of update and ensure completed in a timely manner. Sent the licensing inspector the updated sworn disclosure statement.
Standard #:	8VAC20-790-190-B
Description:	Based on a review of children records, the provider failed to maintain all required information in children records. 1. Child #1?s record was missing the following information for the father: name, home address, phone number, place of employment, employment address, and business phone number. Child 1?s record was also missing a complete address for the person designated by the parent to contact in case of an emergency if the parent cannot be reached. 2. Child #2?s record was missing the mother?s business phone number and the following information for the father: name, home address, home phone number, place of employment, employment address, and business phone number. 3. Child #3?s record was missing the child?s complete home address and phone number, the father?s name, place of employment, employment address, business phone number, home address, and home phone number; the mother?s place of employment and complete home address; and the complete address for the person designated by the parent to contact in case of an emergency if the parent cannot be reached.
Plan of Correction:	The addresses and employment numbers that were missing was completed at the inspection. Some parents didn't provide father information because they didn't know the information. It was immediately taken care of and will make sure all forms are complete best of the parents abilities.
Standard #:	8VAC20-790-210-B
Description:	Based on review of caregiver records, the caregiver failed to ensure that at least every two years from the date of the initial screening or testing, the provider obtained the results of a follow-up tuberculosis screening. Evidence: 1. Caregiver #1?s TB test on file was dated 08/07/2020. 2. Caregiver #1 verified that a follow-up tuberculosis screening had not been completed.
Plan of Correction:	I did have screening at other employment it was late due to COVID they did 2022-2023 together. Will make sure in the future to have updated screening completed before expiration.
Standard #:	8VAC20-790-250-D-1
Description:	Based on a review of caregiver records, the caregiver failed to ensure that the current certification in CPR was appropriate to the ages of children in care. Evidence: 1. The CPR certification certificate dated 08/02/2021 was for certification for adults. 2. On 03/02/2023 there were three children observed in care ranging from ages 10 months-2 years of age.
Plan of Correction:	Will take future classes in time and make sure it includes the ages of children caring for. Immediately set up class and was completed two days after the inspection.
Standard #:	8VAC20-790-250-D-2
Description:	Based on a review of caregiver records, the caregiver failed to ensure that the current certification in First Aid was appropriate to the ages of children in care. Evidence: 1. The First Aid certification certificate dated 08/02/2021 was for certification for adults. 2. On 03/02/2023 there were three children observed in care ranging from ages 10 months-2 years of age
Plan of Correction:	The provider thought the class was completed because they had taken a first aid class. Immediately called and set up class to include child cpr and first aid. It was completed two days after the inspection.
Standard #:	8VAC20-790-250-F
Description:	Based on interview and review of caregiver records, the caregiver failed to obtain required training to include the departments health and safety update. Evidence: 1. There was no documentation or evidence that the annual three-hour health and safety update for 2022 was completed by Caregiver #1. 2. Caregiver #1 verified that she had not completed the three-hour health and safety update for 2022.
Plan of Correction:	Annual 16 hours of training was completed, but did not realize that the annual update was required. I will make sure that one is done every year.
Standard #:	8VAC20-790-260-K
Description:	Based on observation, the provider failed to ensure that stairs shall not be accessible to children less than two years of age. Evidence: On 03/02/2023 the provider had two children, ages 10 months and 19 months, in care. There was not a gate at the bottom of the stairs in the lower level of the home where the children are cared for. The stairs were accessible to all children.
Plan of Correction:	I have the gate it was not set up when the licensing inspector was here. One child tries to climb over. Immediately put the gate up and sent a picture to the inspector as proof.
Standard #:	8VAC20-790-360-I
Description:	Based on observation, the provider failed to ensure that pillows and blankets shall not be used for children less than two years of age. Evidence: On 03/02/2023, at approximately 10:30 A.M., Child #4 (age 10 months) was observed sleeping in a crib. Child #4 was observed laying on his stomach with three blankets in the crib. One blanket was under the child on top of the fitted sheet, one blanket was sitting at the back of the child?s head, and one blanket was covering the body of the child. There was one small pillow located in one of the corners of the crib.
Plan of Correction:	This won't happen again. Took care of immediately after the inspection. Put away all blankets, small decor pillow and bumper pads removed. Sent picture to the licensing inspector as proof.
Standard #:	8VAC20-790-360-K
Description:	Based on observation, the provider failed to ensure that bumper pads on cribs were not used. Evidence: On 03/02/2023, at approximately 10:30 A.M., Child #4 (age 10 months) was observed sleeping in a crib. The crib had a bumper set on all four sides of the crib.
Plan of Correction:	Removed immediately after the licensing inspector left. Sent picture as proof.
Standard #:	8VAC20-790-430-A-1
Description:	Based on review of evacuation drills, the provider failed to ensure that an evacuation drill was practiced at least monthly. Evidence: On 03/02/2023, when the Licensing Inspector was at the home, the provider could not provide evidence that evacuation drills had been completed for July 2022, August 2022, September 2022, October 2022, December 2022, January 2023 and February 2023.
Plan of Correction:	I was given 24 hours to email some paperwork. The fire drill documentation could not be located at the time of the inspection. Emailed to the licensing inspector.