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Lighthouse Worship Center, Inc.
3464 Worth Crossing
Charlottesville, VA 22911
(434) 973-7557

VDSS Contact: Michelle Argenbright (540) 848-4123

Inspection Date: Jan. 15, 2020

Complaint Related: No

Areas Reviewed:
22VAC40-191 Background Checks for Child Welfare Agencies
32.1 Report by person other than physician
63.2 Child Abuse & Neglect
63.2(17) License & Registration Procedures

Comments:
An unannounced monitoring inspection was conducted on 1/15/20 from 10:10 am until 1:15 pm to review the religious exempt requirements. At the time of the inspection 50 children were present with 10 staff. The sample size consisted of five staff's records and 10 children's records. Children and staff were observed during free indoor play, educational and artistic activities, arrival, bathroom break, hand washing, TV time, clean-up, bottle feeding, diapering, story time, transitions and behavioral management. Violations were found during this inspection and are documented on the violation report.
If you have questions or concerns contact the licensing inspector at (540) 848-4123 for additional information.

Violations:
Standard #: 63.2(17)-1716-A
Description: Based on a review of the center's parent handbook and interview, the center failed to ensure a statement of disclosed in writing was provided to parents and guardians of the children in the center the fact the center is exempt from licensure.

Evidence:

1. The parent handbook did not document the exemption status of the center.
2. The director verified the handbook did not contain the exemption status.

Plan of Correction: The exemption letter will be sent home to all current parents and will be added to the parent handbook for future parents of children at the center.

Standard #: 63.2(17)-1716-A-3
Description: Based on observation and interview, the center failed to employ supervisory personnel according to the following ratio of staff to children: 1 staff to 4 children ages 0 to 16 months; 1 staff to 5 children ages 16 months to 24 months; and 1 staff to 8 children age 24 months to 36 months.

Evidence:

1. On 1/15/20 the monkey and ladybug room was combined. Two staff were present with ten children and their ages were as follows:
- 15 months - 24 months
- 15 months - 25 months
- 17 months - 26 months
- 19 months - 26 months
- 21 months - 27 months
2. The director verified the ages of the children. She stated children were transitioned before they turned 16 months and they should not have been.

Plan of Correction: The center will ensure that children are not transitioned into the next age group until they reach the correct age to ensure ratios are being met. Both children that are not yet 16 months will be moved back down into the lower age class until they turn 16 months.

Standard #: 63.2(17)-1716-A-6
Description: Based on a review of the center's parent handbook and interview, the center failed to ensure a written statement was provided to the parents or guardians of the children in the center and made available to the general public that stated the health requirements for staff.

Evidence:

1. The parent handbook did not contain information regarding the health requirements of staff. The handbook only advised staff complied with all health requirements.
2. The director verified the actual health requirements for staff were not provided in writing to parents.

Plan of Correction: The health requirements for staff will be added to the parent handbook and a memo will be provided to the parents of children currently at the center advising of the missing information.

Standard #: 63.2(17)-1716-B-4
Description: Based on record review and interview, the center failed to implement a procedure to ensure that all children in the center are in compliance with the immunizations provisions.

Evidence:

1. The parent handbook states the following: "The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. The center shall obtain documentation of additional immunizations once every six months for children under the age of two years."
2. The center did not implement this procedure for the following children:
- For child 2 the date of birth is 9/24/18 and the date of the last immunization record was dated 5/9/19.
- For child 4 the date of enrollment was 8/13/18 and the date of the immunization record was 8/21/18.
- For child 7 the date of enrollment was 1/15/20 and the file contained no immunization record.
- For child 10 the date of enrollment was 6/24/19, the date of birth was 10/9/18 and the immunization record was not dated.
3. The director stated child 7 just started that day and the mother stated the doctor should have faxed the immunizations.

Plan of Correction: Children's records will be reviewed and parents will be notified to provide updated immunizations if they are missing. In the future a system will be put in place to assist the director in following up with updating immunizations and no child will be allowed in the center until immunization records are received.

Standard #: 63.2(17)-1716-B-5
Description: Based on observation and interview, the center failed to implement a procedure to ensure that all areas of the premises accessible to children are free of obvious injury hazards.

Evidence:

1. The director stated all outlets are to contain outlet covers.
2. In the Butterfly room an outlet under the chalk board did not contain a cover.
In the Busy Bee room an outlet under the chalk board, under the fan and three on the power strip by the TV did not contain covers.
In the Owls room an outlet under the chalk board did not contain covers
3. The director stated all hazardous substances are to be kept on the shelf above the sink.
4. In the bathroom between the Butterfly room and Busy Bee room was a spray can of Air Wick air freshener was on the back of the toilet accessible to children.
In the Owls room on the window sill was a stray can of Lysol.
5. The director stated medication is to be stored in the director's office.
6. In the Jungle room Ibuprofen was stored in a low cubby by the classroom door.
In the Monkey room two medications were on a shelf above the sink.

Plan of Correction: All staff will be retrained on the procedure on hazardous substances and storing medication. The medication will be moved to the director's office. The director will walk through the classrooms weekly to check for hazardous substances.

Disclaimer:

A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. To find programs participating in Virginia Quality, click here.

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