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St. Mark Lutheran Church (ELCA) of Charlottesville, VA
100 Alderman Road
Charlottesville, VA 22903
(434) 293-0792

VDSS Contact: Beth Orebaugh (540) 847-9173

Inspection Date: Aug. 22, 2022

Complaint Related: No

Areas Reviewed:
22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
32.1 Report by person other than physician
54.1 Must be MAT Certified.
63.2 Child abuse and neglect
8VAC20-770 Background Checks

Technical Assistance:
Fingerprint background checks must be completed prior to hire.

Comments:
An unannounced code compliance inspection was initiated on 8/22/2022 and concluded on 8/22/2022 from 10:20 AM to 11:45 AM. There were 38 children present, ranging in ages from two to five, with 12 staff. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, procedures and medication. A total of three children?s records and three staff?s records 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 facility.

Violations:
Standard #: 22.1-289.031-A-4
Description: Based on record review and interview, the center failed to ensure each staff member has been certified by a physician, physician assistant, or nurse practitioner to be free from any disability which would prevent him from caring for children under his/her supervision.

Evidence:

1. The record for staff 1 documented the start date as 6/27/22. The record did not contain a staff health report.
2. The director verified the center did not obtain a staff health report for staff 1.

Plan of Correction: Staff 1 will schedule to obtain a staff health report as soon as possible. In the future staff will not be allowed to start work until a staff health report is provided.

Standard #: 8VAC20-770-40-D-2
Description: Based on record review and interview, the center failed to have a completed central registry record check by the end of the 30th day of employment.

Evidence:

1. The record for staff 1 documented the start date as 6/27/22. The record did not contain the results of a central registry background check. The record did contain the receipt of payment for the central registry background check dated 7/19/22.
2. The director verified the results for the central registry background check have not been received and the center has not followed up.

Plan of Correction: The director will follow up to find the status of the results of the central registry background check and will keep the licensing inspector informed. In the future central registry background check paperwork will be completed upon hire and followed up on if results are not received within 30 days.

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.

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