VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ms. Ligia Pavon
2113 Patrick Street
Woodbridge, VA 22191
(703) 398-2836

Current Inspector: Beth Velke (804) 629-8302

Inspection Date: Jan. 31, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-111 Administration 22VAC40-111 Personnel 22VAC40-111 Household Members 22VAC40-111 Physical Health of Caregivers and Household Members 22VAC40-111 Caregiver Training 22VAC40-111 Physical Environment and Equipment 22VAC40-111 Care of Children 22VAC40-111 Preventing the Spread of Disease 22VAC40-111 Medication Administration 22VAC40-111 Emergencies 22VAC40-111 Nutrition 22VAC40-111 Transportation 63.2 Licensure and Registration Procedures

Technical Assistance:

Discussed with the provider the follow-up and documentation needed for out-of-state background checks as well as the timing of additional background checks, TB tests, and annual training.

Comments:

An unannounced renewal inspection was conducted today from 9:30am to 2:15pm with the provider and two assistants. There were 12 children in care, ranging from two months to five years of age, for a total of 29 points. Children were observed finishing breakfast, washing hands, singing and dancing, talking about the days of the week and their body parts in English and Spanish, reading books, doing worksheets, playing dress up, having lunch, and napping. Five children?s records, four caregiver records, and two household members? records were reviewed. The provider has current certification in CPR and First Aid. The provider stated that there is no medication on site but she has current certification in Medication Administration Training (MAT). Breakfast today was pancakes, pineapple and milk and lunch was rice, scrambled egg, green beans, carrots, and milk. The first aid kit, flashlight, and weather band radio were observed and were in compliance. The emergency drill log was reviewed and was in compliance. Please notify the Licensing Inspector when you have received the results of the background checks. If you have questions regarding this inspection, please contact the Licensing Inspector, Laura Brindle, at laura.brindle@dss.virginia.gov or 540-905-2062.

Violations:

Standard #:	22VAC40-111-100-A
Description:	Based on review of five children's records, the provider did not obtain documentation of a physical examination by a physician within 30 days after the first day of attendance for all children. Evidence: The records for Child A, with a start date of 5/9/19, and Child B, with a start date of 7/8/19, did not contain documentation of a physical.
Plan of Correction:	I will get this from the parents.
Standard #:	22VAC40-111-50-A
Description:	Based on review of documentation and observation, the provider did not ensure all children were included on the written attendance record. Evidence: The written attendance had documentation of 10 children in care, but there were 12 children present.
Plan of Correction:	We will make sure to have an accurate attendance.
Standard #:	22VAC40-111-180-A
Description:	Based on review of documentation, the provider did not obtain subsequent Tuberculosis (TB) tests or screenings for each caregiver or adult household member every two years from the date of the first screening. Evidence: The TB test or screening on record for Caregiver C was dated 6/27/17; and the TB test or screening on record for Household Member A was dated 9/21/17.
Plan of Correction:	I believe both of them have received updated TB tests, I just need to get the documentation for their files.
Standard #:	22VAC40-111-210-A
Description:	Based on review of documentation and interview with the provider, the provider did not obtain a minimum of 16 hours of annual training. Evidence: 1. The record for the provider included training certificates for 10.5 hours of annual training. 2. The provider stated that she did not have any other training certificates for the past year.
Plan of Correction:	I will make sure to make up the other hours within two months and will get 16 moving forward.
Standard #:	22VAC40-111-530-F
Description:	Based on observation, soft bedding was used under and around infants. Evidence: The Licensing Inspector observed a two month old in a crib surrounded by four filled comforters and laying on top of an additional filled comforter.
Plan of Correction:	Moving forward we will not use any soft bedding in the cribs.
Standard #:	63.2-1720.1-A
Description:	Based on review of documentation, the provider did not obtain repeat sworn statements or central registry check results within five years of the dates of the last sworn statement or central registry check results for each staff. Evidence: 1. The sworn statement on record for Caregiver B was dated 7/7/14. 2. The results of the central registry check for Caregiver C were dated 11/21/13.
Plan of Correction:	I will get these updated as soon as possible.
Standard #:	63.2-1720.1-B-3
Description:	Based on review of documentation and interview with the provider, the provider did not obtain the results of a search of the central registry or equivalent registry maintained by another state in which an employee lived in the previous five years. Evidence: The sworn statement for Caregiver A, signed 8/6/19, disclosed that she had lived in Maryland within the past five years, but the record did not contain the results of a central registry search from Maryland.
Plan of Correction:	I completed the request after she started but I never received anything back. I completed a second request 1/13/20. I will follow up with the second request within 45 days and will document my attempts moving forward.