VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Jennifer Rivera Rodriguez
175 Queen Victoria Street
Culpeper, VA 22701
(540) 229-7684

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: Jan. 5, 2023

Complaint Related: Yes

Areas Reviewed:

8VAC20-800 Administration 8VAC20-800 Personnel 8VAC20-800 Household Members 8VAC20-800 Caregiver Training 8VAC20-800 Physical Equipment and Environment 8VAC20-800 Care of Children 8VAC20-820 THE LICENSE. 8VAC20-770 Background 22.1 Background Checks Code, Carbon Monoxide

Comments:

The licensing inspector conducted an unannounced inspection in response to a complaint received by the department on 01/04/2023 on 01/05/2023. A follow-up inspection was completed on 01/23/2023 and 02/14/2023. Interviews, documentation review, and observations were conducted based on allegations relating to the allegations related to supervision, ratios, and capacity. The information gathered during the investigation does support the allegation in part; therefore, the complaint is determined to be valid. Areas of non-compliance are identified on this Violation Notice. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 10 calendar days from today. Specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, contact your licensing inspector at (540) 848-4123. The inspection findings have been updated as a result of a first step review completed on 04/01/2023.

Violations:

Standard #:	22.1-289.036-A
Complaint related:	No
Description:	REPEAT VIOLATION 22.1-289.036-A Based on record review and interview, the provider failed to obtain a copy of the results of a search of the central registry every five years. Evidence: A record review was conducted on 01/23/2023. The most recent results of a search of the central registry for the provider was dated 03/24/2017.
Plan of Correction:	Provider has reviewed 22.1-(14.1)-289.036-A. Provider will ensure that the correct central registry searches are conducted, and results are obtained, every five years, and the Provider will also use a better record keeping system to ensure backgrounds are completed prior to expiration. Provider has been in compliance since 2/6/2023.
Standard #:	8VAC20-770-40-D-4-a
Complaint related:	No
Description:	Based on interview, the provider failed to obtain a sworn statement by the first day of residence for a new household member, aged 18 years or older and central registry background check results for a household member by the end of the 30th day of residence. Evidence: 1. Per interview with the provider, household member 1 has lived in the home since 12/10/2022. 2. The provider stated she had not obtained a sworn statement from household member 1. 3. Per interview with the provider, household member 1 has lived in the home since 12/10/2022. 4. The provider stated she has not requested a central registry for household member 1 as of 01/ 23/2023.
Plan of Correction:	Provider has reviewed 8VAC20-770-(BC)-40-D-4-a. Provider will ensure that a sworn statement is obtained by the first day of residence for a new household member, aged 18 years or older, and that central registry background check results are obtained for a household member by the end of the 30th day of residence. Provider will obtain all signatures and backgrounds immediately for new hires and new household members. Provider has been in compliance since the inspection date.
Standard #:	8VAC20-800-30-A
Complaint related:	No
Description:	Based on observation, documentation and interview, the provider failed to ensure compliance with these standards and the terms of the current license issued by the department and with relevant federal, state, or local laws, and other relevant regulations. Evidence: 1. Per Code of Virginia 22.1-289.011 states, every person who constitutes, or who operates or maintains, a child day program or family day system shall obtain the appropriate license from the Superintendent, which may be renewed. Per the Standards for Licensed Child Day Centers a child day center is defined as a child day program offered to two or more children younger than 13 years of age in a facility that is not the residence of the provider or of any of the children in care or 13 or more children at any location. It was determined on 01/05/2023 the provider was operating a child cay center and did not have a license to operate a child day center. 2. On 01/05/2023 15 children were observed in care and the provider was notified she was operating illegally. 3. On 01/23/2023 14 children were observed in care and the provider was notified she was operating illegally.
Plan of Correction:	NOT IN AGREEMENT WITH VIOLATION! DOCUMENTATION IN HAND! REQUESTING DESK REVIEW AND PROBLEM SOLVING CONFERENCE!
Standard #:	8VAC20-800-40-A
Complaint related:	No
Description:	Based on interviews and observation, the provider failed to ensure that the total number of children receiving care at any one time does not exceed the maximum licensed capacity of the home. Evidence: 1. The licensed capacity of the home is 12. Per discussion with the provider on 01/23/2023 and verification with parents, 17 children were in care from 10/14/2022 until 12/16/2022. Per interviews with parents, each child attended on a regular basis, Monday - Friday with drop off times typically ranging from 7:00AM-8:30AM and pick up times typically ranging from 3:00 PM to 5:30 PM. 2. On 01/05/2023 at approximately 11:36 AM, a total of 15 children were observed in care. 3. On 01/23/2023, 14 children were observed in care, and the provider verified that there were 14 children in care. 4. Per the attendance sheets the 14 children remained in care until 02/03/2023. The attendance sheet documented 02/03/2023 was the last date of attendance for one child.
Plan of Correction:	Provider has reviewed 8VAC20-800-(2)-40-A. Provider will ensure that the total number of children receiving care at any one time does not exceed the licensed capacity for the home and remains at 12 or under through improved methods for tracking attendance. Provider has been in compliance with this standard since the inspection date.
Standard #:	8VAC20-800-480-D
Complaint related:	No
Description:	Based on observation and interview, the provider failed to use equipment in accordance with the manufacturer?s instructions. Evidence: 1. On 02/14/2023, child 1, age 7 months, and child 2, age 6 months, were observed lying asleep on Boppy pillows. The manufacturer?s instructions attached to the Boppy pillow state: ?Awake time only; Not for sleeping.? 2. On 02/14/2023 the provider stated she used Boppy pillows to prop three infant?s heads up in cribs while they were sleeping.
Plan of Correction:	Provider has reviewed 8VAC20-800-(7)-480-D. Provider has reviewed manufacturer instructions for Boppy Pillows to ensure they are assembled, maintained, and/or used in accordance with those instructions, and Provider has removed all Boppy Pillows from all infant cribs. Provider has been in compliance with this standard since the inspection date.
Standard #:	8VAC20-800-520-A
Complaint related:	No
Description:	Based on interviews, the provider failed to ensure that cribs were provided for children from birth through 12 months of age. Evidence: 1. Interviews with four parents revealed that per observation and discussions with provider, their infants had slept in bassinets during nap times. 2. Interview with the provider on 01/23/2023 confirmed that she did use a bassinet for infants to nap.
Plan of Correction:	Provider has reviewed 8VAC20-800-(7)-520-A. Provider will ensure cribs are provided for children as required by the standard, and Provider has discontinued use of bassinets for all aged infants. Provider has been in compliance since the inspection date.
Standard #:	8VAC20-800-530-F
Complaint related:	No
Description:	Based on observation, the provider failed to ensure that no soft bedding of any kind was used under or around infants including, but not limited to, pillows, quilts, comforters, sheepskins, or stuffed toys. Evidence: On 02/14/2023, child 1, age 7 months, and child 2, age 6 months, were observed sleeping in cribs while lying on a Boppy pillow.
Plan of Correction:	Provider has reviewed 8VAC20-800-(7)-530-F. Provider has removed Boppy Pillows from all infant cribs. Provider has been in compliance with this standard since the inspection date.
Standard #:	8VAC20-800-560-A
Complaint related:	No
Description:	Based on observation, the provider failed to ensure that a caregiver always provided direct care and supervision of each child. Evidence: On 01/05/2023, at approximately 11:36 AM, three children, each two years of age, were found alone in a room on the second floor of the house, with household member 1, who is not a caregiver. The three children remained upstairs with household member 1 during the remainder of the inspection, which was approximately 30 minutes.
Plan of Correction:	Provider has reviewed 8VAC20-800-(8)-560-A. Provider will ensure that all daycare children remain on the lower level of the daycare with an approved caregiver. Provider has been in compliance with this standard since the inspection date.
Standard #:	8VAC20-800-570-A
Complaint related:	No
Description:	Based on interview and observation, the provider failed to ensure that each caregiver did not exceed 16 points to determine need for additional caregivers. Evidence: 1. Interviews with 15 parents to verify the date that each child started in care and their birth date revealed that the provider was caring for 17 children for approximately two months (October 2022 through December 16, 2022). The total points for 17 children is 53 and there were only three caregivers, including the provider, during this period which would only allow for 48 points. 2. Interview with the provider on 01/23/2023 verified that she was caring for 17 children from 10/14/2022 through 12/16/2022. The provider confirmed there were only three caregivers including herself during this period.
Plan of Correction:	Provider has reviewed 8VAC20-800-(8)-570-A. Provider will ensure that point and staffing requirements are met with improved methods for tracking attendance and enrollment. Provider has been in compliance since the inspection date.