VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Laura Marshall-Norris
12541 Bunche Road
Fairfax, VA 22030
(703) 929-2625

Current Inspector: Stacy Doyle (571) 835-0386

Inspection Date: Aug. 7, 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 54.1 Provider must be MAT certified to administer prescription medication.

Comments:

An unannounced renewal inspection was conducted today from 2:30pm-4:00pm with the provider on site. There were 7 children (17 points) with 1 caregiver. A sample of 2 children's files and 5 caregivers/household member's files were reviewed. The children were engaged in the following: napping. The site contained an abundant supply of developmentally appropriate materials. The physical space, attendance records, first aid kit, drill record and the Emergency Preparedness Plan were reviewed. There were no medications on site. Areas of non-compliance are identified in the violation notice. Please contact me if you have any questions at Stacy.Doyle@doe.virginia.gov or 571-835-0386.

Violations:

Standard #:	22.1-289.011-F
Description:	Based on observation, the last inspection summary and violation notice were not posted in a conspicuous place on the premises. Evidence: 1. The provider had the acknowledgement form dated 5/23/2023 posted, but did not have the inspection summary or violation notice from 5/23/2023 posted.
Plan of Correction:	Notice was being reviewed and was reposted.
Standard #:	8VAC20-770-60-C-2
Description:	Based on review of caregiver records, the provider did not have the central registry findings within 30 days of employment for one caregiver. Evidence: 1. Caregiver #2 (approximate start date 4/2024) did not have the central registry findings in the file. The provider had a copy of the front of the form that was filled out to be sent.
Plan of Correction:	Original registry form mailed 4/29/2023. It was returned for signature and has since been resubmitted.
Standard #:	8VAC20-800-830-D
Description:	Based on review of the drill record and interview, the provider did not maintain records of emergency evacuation drills for one year. Evidence: 1. The drill record was missing the May 2023 and June 2023 evacuation drill record information. 2. The provider stated she practiced the drill, but only wrote down the Lockdown drill May 26, 2023 and the shelter in place drill June 30,2023. She stated she did the evacuation drill the same days as the lockdown drill and shelter in place drill.
Plan of Correction:	Will revise form to include space for Fire drills also.
Standard #:	8VAC20-800-120-B
Description:	Based on review of the assistant's records, the records did not contain all required documents. Evidence: 1. Caregiver #2's file (Approximate start date 4/2024) was missing verification of age, date of employment, documentation of tuberculosis screening, Virginia Central Registry results and two references,
Plan of Correction:	Age verification and references have been filed. Original registry form mailed 4/29/2023. It was returned for signature and has been resubmitted. Appointment for TB has been scheduled.
Standard #:	8VAC20-800-170-A
Description:	Based on documentation review, the provider did not obtain from each caregiver at the time of hire a current report of tuberculosis screening with it documenting the absence of tuberculosis in a communicable form. Evidence: 1. Caregiver #2 (approximate start date 4/2024) did not have documentation of a current report of tuberculosis screening.
Plan of Correction:	TB appointment has been scheduled.
Standard #:	8VAC20-800-210-A
Description:	Based on review, one caregiver did not obtain a minimum of sixteen clock hours of training annually in areas relevant to their job responsibilities. Evidence: 1. Caregiver #1 had 10.5 hours of training in 2023 and did not have training certificates/documentation of training in 2022.
Plan of Correction:	Virtual trainings during pandemic will be located and properly filed.
Standard #:	8VAC20-800-280
Description:	Repeat Violation , Based on observation, potentially poisonous substances, materials and supplies such as, but not limited to, cleaning agents, disinfectants and deodorizers were not stored away in areas inaccessible to children. Evidence: 1. A toilet bowl cleaning product was stored under the bathroom sink that children use. Another cleaning product was inside the shower/tub that had fallen off a shelf in the bathroom children use.
Plan of Correction:	Products placed out of reach.
Standard #:	8VAC20-800-570-A
Description:	Based on observation and interview, the provider did not ensure that a caregiver did not exceed 16 points. Evidence: 1. The caregiver had 7 children with a total points value of 17 points. (1) 9 month old - 4 points (1) 23 month old - 3 points, (5) 2 years-4 years old-2 points each for a total of 10 points 2. The caregiver stated the assistant was not present today.
Plan of Correction:	Currently hiring an additional staff member.