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Ms. Sandra Nicholas
2801 Montclair Court
Richmond, VA 23223
(804) 329-8830

Current Inspector: LaTasha Smith (804) 588-2362

Inspection Date: Jan. 25, 2022

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
22VAC40-191 Background Checks for Child Welfare Agencies
22.1 Background Checks Code; carbon monoxide detectors

Technical Assistance:
n/a

Comments:
A renewal inspection was initiated on 01/25/2022 and concluded on 01/27/2022. The provider submitted documentation to the inspector on 01/25/2022 and the inspector conducted an unannounced inspection on-site on 01/27/2022 from approximately 3:45pm to 5:30pm. There were 8 children present with two caregivers. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of two child records, two caregivers' records, and one household member'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 program.

Violations:
Standard #: 22.1-289.035-B-2
Description: Based on a review of two caregivers' records and interview, the provider did not ensure one caregiver obtained fingerprints prior to hire.

Evidence: 1) The record for Caregiver #2, hired on 10/21/2021, did not contain a fingerprint-based background check determination letter from the Office of Background Investigation prior to employment. 2) During interview, a Caregiver #1 confirmed the fingerprint-based background check results for Caregiver #2 have not been received.

Plan of Correction: Caregiver #2 will get fingerprints as soon as possible. The results will be filed upon receipt.

Standard #: 8VAC20-770-60-B
Description: Based on a review of two caregivers' records and interview, the provider did not ensure one caregiver had a complete sworn statement or affirmation prior to employment.

Evidence: 1) The sworn statement in the file for Caregiver #2, hired on 10/29/2021, was dated 01/05/2022. 2) During interview, Caregiver #1 confirmed the sworn statement for Caregiver #2 was completed after their hire date.

Plan of Correction: The sworn statement is already complete. In the future, caregivers will be required to complete a sworn statement prior to employment.

Standard #: 8VAC20-770-60-C-2
Description: Based on a review of two caregivers' records, the provider did not ensure one caregiver had a central registry finding within 30 days of employment.

Evidence: 1) The record for Caregiver #2, hired on 10/29/2021, did not contain a central registry finding. 2) During interview, Caregiver #1 reported the central registry finding for Caregiver #2 has not been received.

Plan of Correction: The request will be mailed to the office of background investigation and the results filed upon receipt.

Standard #: 8VAC20-800-120-A
Description: Based on a review of two caregiver records, one caregiver's record did not contain the required documentation.

Evidence: 1) The record for Caregiver #2, hired on 10/29/2021, did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment. The record did not contain documentation of the Caregivers' education and training as required by 8VAC20-800-230.

Plan of Correction: The orientation for Caregiver #2 will be completed and signed. The references will be obtained by the end of the week.

Standard #: 8VAC20-800-60-B
Description: Based on a review of two children's records and interview, the provider did not ensure one child's record contained the required information.

Evidence: 1) The record for Child #1, enrolled on 01/24/2022, did not contain a second emergency contact. A child's record should contain the name, address, and telephone number of two designated persons to contact in case of an emergency if a parent cannot be reached. 2) The record for Child #1 did not contain the parent's signed acknowledgement of the receipt of the information required by 8VAC20-800-70. 3) During interview, Caregiver #1 acknowledged the information was not in the child's record.

Plan of Correction: The parent was given the necessary forms to sign and complete by 01/28/22.

Standard #: 8VAC20-800-90-A
Description: Based on a review of two children's records and interview, the provider did not obtain documentation that one child had been adequately immunized before the child may attend the family day home.

Evidence: 1) The record for Child #1, enrolled on 01/24/2022, did not contain documentation that the child has been adequately immunized. 2) During interview, Caregiver #1 reported the documentation has not been obtained to date.

Plan of Correction: The records have been requested. In the future, immunizations will be obtained prior to enrollment.

Standard #: 8VAC20-800-170-A
Description: Based on a review of two caregivers' records and interview, the provider did not obtain from one caregiver at the time of hire a current report of tuberculosis (TB) screening form published by the Virginia Department of Health or a form consistent with it documenting the absence of tuberculosis in a communicable form.

Evidence: 1) The record for Caregiver #2, hired on 10/29/2021, did not contain documentation of a TB screening. 2) During interview, Caregiver #1 reported Caregiver #2 does not have a current TB screening on file.

Plan of Correction: Caregiver #2 will be asked to provide a complete TB screening as soon as possible.

Standard #: 8VAC20-800-680-A
Description: Based on observations and interview, a caregiver did not wash their hands with soap and warm running water after diapering a child.

Evidence: 1) During the inspection, Caregiver #2 was observed diapering a child. Caregiver #2 did not wash their hands with soap and water after diapering the child. Caregivers shall wash their hands with liquid soap and warm running water after diapering a child or assisting a child with toileting. 2) During interview, Caregiver #1 reported Caregiver #2 has been reminded to wash their hands with soap and warm running water after diapering a child.

Plan of Correction: Caregiver #2 has been reminded to wash their hands with soap and warm running water after diapering a child.

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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