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Donna Conway
26105 Lafayette Dr.
Rhoadesville, VA 22542
(540) 732-0901

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: March 14, 2023

Complaint Related: No

Areas Reviewed:
8VAC20-800 Administration
8VAC20-800 Personnel
8VAC20-800 Household Members
8VAC20-800 Physical Health of Caregivers and Household Members
8VAC20-800 Caregiver Training
8VAC20-800 Physical Equipment and Environment
8VAC20-800 Care of Children
8VAC20-800 Preventing the Spread of Disease
8VAC20-800 Medication Administration
8VAC20-800 Emergencies
8VAC20-800 Nutrition
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-770 Background Checks
22.1 Background Checks Code, Carbon Monoxide

Comments:
An unannounced renewal inspection was conducted on-site March 14, 2023. The provider was available during the inspection. There were 7 children present, ranging in ages from 15 months to 5 years, with 2 staff supervising. 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 5 child records, 1 household member record and 2 staff 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.

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 5 business days from today. Please 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 preventative measures. Please do not use staff names; list staff by positions only.

Violations:
Standard #: 8VAC20-800-830-B
Description: Based on a review of shelter-in-place records and interview on 03/14/2023, the provider failed to ensure to implement a minimum of two shelter-in-place drills per year.
Evidence: 1. There was no documentation of shelter-in-place drills being conducted in 2022. 2. The provider confirmed the two shelter-in-place drills were not conducted.

Plan of Correction: Make sure shelter-in-place drills are done at least 2 x per year.

Standard #: 8VAC20-800-830-C
Description: Based on a review of the fire drill log and interview on 03/14/2023, the provider failed to ensure documentation shall be maintained of emergency evacuation and shelter-in-place drills.
Evidence: 1. There was no documentation of a fire drill being conducted in February 2023. 2. The provider stated the drill was conducted but not recorded on the log.

Plan of Correction: Make sure all drills are recorded.

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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