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Mary Bethune Academy
2249 Halifax Street
Lynchburg, VA 24501
(434) 847-4221

Current Inspector: Victoria E Dawson (540) 309-2674

Inspection Date: Oct. 21, 2015

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-191 Background Checks (22VAC40-191)

Comments:
An unannounced monitoring visit was conducted on 10/22/2015 and 10/24/2015 There were 38 children total in care with nine staff present. The inspector arrived at 9:30 A.M. and departed the program at 12:15 P.M. and on 10/24/2014 the inspector arrived at 11:30 A.M. and departed at 1:00 P.M. The inspector reviewed five children's and three staff's records during the inspection.

Children were observed during: free play, outside time, lunch, nap, quiet activities, afternoon snack, departure on bus and play time.

Discussion with site director and director about: using the work study students as staff unless a complete records is obtained, moving the violation notice to an area that is conspicuous to the public, and program lead qualifications.

Violations:
Standard #: 22VAC40-185-150-B
Description: Based on review of three children's records, the center failed to ensure that all records were complete. Evidence: 1. The inspector found that child # 2 did not have a physician's signature and date on the immunization record.

Plan of Correction: The office staff will obtain a signed immunization and will monitor all records.

Standard #: 22VAC40-185-160-A
Description: Based on review of three staff records, the center failed to ensure that all TB screenings were completed within 21 days of hire or completed 12 months prior to employment.

Evidence:
1. The inspector found that staff # 1 was hired on 8/24/2015 and the most recent TB screening was completed on 7/09/2014. This was more than 12 months prior to employment.

Plan of Correction: The office staff will monitor all records and staff will obtain a new TB screening.

Standard #: 22VAC40-185-160-C
Description: Based on review of three staff records, the center failed to ensure that all repeat TB screenings were completed every two years.

Evidence:
1. The inspector found that staff # 3's most recent TB screening was 4/12/2013.

Plan of Correction: The staff person will obtain a new TB screening and will monitor.

Standard #: 22VAC40-185-70-A
Description: Based on review of three staff records, the center failed to ensure that all records were complete.

Evidence:
1. The inspector found that staff # 1 and 2 did not have the two required references, age verification, job title, and emergency contact.
2. Staff # 2 did not have a start date.

Plan of Correction: The office staff will obtain the missing information and will monitor all records.

Standard #: 22VAC40-185-240-A
Description: Based on review of three staff records, the center failed to ensure that all staff received orientation training by the end of their first day of assuming job responsibilities.

Evidence:
1. The inspector found that staff # 2 and 3 did not have documentation of orientation training prior to the first day of assuming job responsibilities.

Plan of Correction: Office staff and director will make sure that all work study student have orientation and all required information.

Standard #: 22VAC40-185-420-E-1
Description: Based on review of the infant log, the center failed to ensure that all items required were on the log.

Evidence:
1. The inspector found that the following was missing from the infant communication log with parents: tummy time and developmental milestones.

Plan of Correction: The infant teacher will make a new log and start using it as soon as possible.

Standard #: 22VAC40-185-430-I
Description: Based on observation of the infant room, the center failed to ensure that all personal articles were individually assigned. Evidence: 1. The inspector found two pacifiers that were not labeled with the child's name.

Plan of Correction: The director will remind staff to label all pacifiers.

Standard #: 22VAC40-185-510-E
Description: Based on observation, the center failed to ensure that all medications were labeled. Evidence: 1. The inspector found a medication in the first aid cabinet in the adult bathroom that was not labeled.

Plan of Correction: The office staff will discard the medication and will monitor all areas.

Standard #: 22VAC40-185-510-N
Description: Based on review of medications, the center failed to ensure that all medications were returned to the parent or guardian. Evidence: 1. The inspector found a medication for child # 6, this child no longer attends the program. The medication was not returned to the parent.

Plan of Correction: The director will discard the medication properly and will monitor all medications.

Standard #: 22VAC40-185-540-A
Description: Based on review of the down stairs first aid kit, the center failed to ensure that all items were in the first aid kit. Evidence: 1. The inspector found that the down stairs first aid kit was missing the following items: gauze pads, two triangular bandages, gloves and tape.

Plan of Correction: The director will make sure that the first aid kit is complete on every floor.

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.

Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. Eligible child care facilities must be fully licensed, licensed exempt and a VDSS subsidy vendor, or a voluntary registered day home and a VDSS subsidy vendor. Only programs enrolled in Virginia Quality will display a rating. Virginia Quality contact information for your region is available at the following link Regional Contacts.

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