VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: LaTasha Smith (804) 588-2362

Inspection Date: Jan. 11, 2024

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 8VAC20-770 Background Checks 22.1 Background Checks Code, Carbon Monoxide 54.1 Provider must be MAT certified to administer prescription medication.

Comments:

A renewal inspection was conducted on January 11, 2024 from 12:30pm until 1:50pm. There were 9 children present, ranging in ages from 7 months to 2 years, with 2 caregivers 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, 2 caregiver records, and 1 household members record 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 preventive measure(s). If you have any questions, please contact the inspector LaTasha Smith at (804) 588-2362 or LaTasha.Smith@doe.virginia.gov.

Violations:

Standard #:	8VAC20-770-40-D-1-a
Description:	Based on record review and interview, the provider failed to ensure that all staff shall undergo background checks every five years. Evidence: 1. The staff record for Staff #1 contained a central registry background dated 6/8/2018. Staff #1 should have undergone a criminal background check on or before 6/8/2023. 2. The provider verified that a central registry background check had not been completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-770-40-D-4
Description:	Based on record review, the provider did not update background check documentation for a household member every 5 years. Evidence: Household member # 1's record contains a central registry check that was last updated on 12/15/2018. Household member #1 should have completed an updated central registry background on or before 12/15/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-800-100-A
Description:	(Repeat Violation) Based on review children records, the provider did not obtain documentation of a physical examination (by or under the direction of a physician) within 30 days after the first day of attendance. Evidence - 1. The record for child # 4, did not contain documentation of a physical examination. Child # 4?s date of enrollment was 8/28/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-800-60-B
Description:	(Repeat Violation) Based on record review, the record of each child was not complete. Evidence: Child #4 did not have documentation of proof of identification.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-800-90-A
Description:	(Repeat Violation) Based on review children records, the provider did not obtain documentation of immunizations before a child may attend the family day home. Evidence - 1. The record for child #4, did not contain documentation of immunizations.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-800-180-A
Description:	Based on record review, the provider did not obtain a current report of tuberculosis screening/test for each household member/caregiver every two years from the date of the last test/screening. Evidence: Staff#1's record contains a TB test/screening that was last updated on 5/12/2018.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-800-210-A
Description:	Based on review of records, the provider did not ensure that all staff receive the required 16 hours of annual training. Evidence: Staff #2 received a total of 4 hours of annual training.
Plan of Correction:	Not available online. Contact Inspector for more information.