VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greater Mt. Calvary Christian Church
9514 Westmoreland Avenue
Manassas, VA 20110
(703) 368-5941

VDSS Contact: Laura Brindle (540) 905-2062

Inspection Date: March 8, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-665 INTRODUCTION 22VAC40-665 ADMINISTRATION 22VAC40-665 STAFF QUALIFICATIONS & TRAINING 22VAC40-665 PHYSICAL PLANT 22VAC40-665 STAFFING & SUPERVISION 22VAC40-665 SPECIAL CARE PROVISIONS & EMERGENCIES 22VAC40-665 SPECIAL SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contact, documentation review, interview, and a virtual tour of the program. A subsidy health and safety inspection (SHSI) was initiated on 3/8/22 and concluded on 3/25/22. There were three children present with one staff supervising. A Code Compliance inspection was also conducted on this date. Both inspections combined cover subsidy health and safety regulations. Subsidy requirements that are not covered in the Code Compliance inspection were reviewed during this supplemental inspection. Information gathered during the inspection determined non-compliance and violations were documented on the violation notice issued to the program. Please complete the "Plan of Correction" and "Date to be Corrected" areas on the Violation Notice for each violation cited and return to me by close of business on 3/30/22. Plans of correction should include steps to correct the noncompliance with the standard, and measures to prevent the noncompliance from occurring again. If you have questions regarding this inspection you may contact the Licensing Inspector, Laura Brindle, at laura.brindle@doe.virginia.gov or 540-905-2062.

Violations:

Standard #:	22VAC40-665-510-B
Description:	Based on documentation review, the program did not maintain a written record of daily attendance that documented the arrival and departure of each child in care as it occurred. Evidence: Attendance submitted contained check marks to document whether or not a child attended for the day, but did not include documentation of arrival and departure of children as it occurred.
Plan of Correction:	After speaking with the Licensing Inspector during the virtual inspection on how attendance should be recorded it was corrected.
Standard #:	22VAC40-665-520-B-7
Description:	Based on review of three child records, the program did not obtain documentation of immunizations for a child on or before their first day of attendance. Evidence: The record submitted for Child A, with a start date of 8/16/21, did not contain documentation of immunizations.
Plan of Correction:	The parent of child #3 will ensure that I receive a copy of the immunization record for the child.
Standard #:	22VAC40-665-580-H
Description:	Based on review of two staff records, the program did not ensure that staff who work directly with children completed at least 16 hours of training annually. Evidence: Annual training was requested as part of the inspection, but no annual training was submitted by the program for Staff #1 or Staff #2.
Plan of Correction:	We will ensure that the staff will complete 16 hours of annual training. Also, the staff is in the process of taking the 2022 Virginia Pre-service online training.
Standard #:	22VAC40-665-580-K
Description:	Based on review of two staff records, the program did not ensure that there was at least one staff on duty who had obtained Daily Health Observation training (DHO) within the last three years. Evidence: The DHO training certificates on record for Staff #1 and Staff #2 were dated 9/27/18.
Plan of Correction:	We will ensure that the staff will enroll in the next daily health observation training that is available.
Standard #:	22VAC40-665-780-A-1
Description:	Based on documentation review and interview, the program did not ensure that evacuation procedures were practiced as least monthly. Evidence: The drill log submitted did not contain documentation of an evacuation drill practiced in January 2022 or February 2022.
Plan of Correction:	The program evacuation procedures were practiced three times for the month of March and will continue monthly.