1631 Blue Hills Drive
Roanoke, VA 24012
Current Inspector: Julia Kimbrough (276) 608-4267
Inspection Date: March 14, 2016
Complaint Related: No
- Areas Reviewed:
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
22VAC40-80 THE LICENSE.
22VAC40-191 Background Checks (22VAC40-191)
An unannounced monitoring inspection was conducted in the Center on March 14, 2016 by Licensing Inspector, Elaine Moore. As reported by the Program Director, 105 children are currently enrolled in the program. The LI observed 7 classrooms operating with a total of 90 children in care. The ages of the children ranged from 3 months to eleven years old. There were 14 staff members supervising the children's activities. The LI observed varied activities during the inspection to include: hand washing practices, diapering procedures, medications, meals, nap/rest time, free play, structured homework time and dismissal procedures at the end of the day. Staff were observed interacting with the children. Each classroom was supplied with age appropriate toys and equipment. A sample of 14 records was reviewed which included 7 children's and 7 staff records. The Center does not prepare meals/snacks on site, foods are provided by each child's parent. Documentation of the Center's annual fire and health inspections was current. The following was discussed with the PD: practiced evacuation drills, the installed fire alarm system should be activated with each drill and drills conducted at times of the program day to include the majority of the enrolled children in care; Safe sleep practices were discussed with the PD and resource information provided about Safekids.org.; and 2 credit hours are earned for completion of the on-line child abuse and neglect course. The on-site inspection was conducted from approximately 11:15am to 5:30pm. Findings of the inspection were reviewed and a plan of correction was given by the PD. The acknowledgment of inspection form was prepared and left for the Center to post. The final report was provided on March 15, 2016. Thank you for your assistance during this inspection.
Standard #: 22VAC40-185-270-A Description: Based on the LI's observations, the Center failed to maintain all areas of the center in a clean, safe condition. Evidence: The LI observed 2 water stained ceiling tiles in an infant room (classroom 2). Plan of Correction: The Center Director will have the stained ceiling tiles replaced.
Standard #: 22VAC40-185-280-B Description: Based on the LI's observations, the Center failed to keep hazardous substances in a locked place. Evidence: The LI observed a posting on a door in the school-age classroom which read electronics/fire alarm. The door was not locked and opened by the LI. The closet contained an electric panel box, cans of paint, and a large blue bag of ice melt. Upon notice, staff locked the door. Plan of Correction: The PD will review the Center's opening/closing procedures with staff to ensure all areas used for storage are kept locked when children are in care.
Standard #: 22VAC40-185-350-E-4 Description: Based on the LI's observations, the Center failed to comply with the required staff to children ratios wherever children are in care. For children from three years to the age of eligibility to attend public school: one staff member for every10 children. Evidence: The LI observed 11 children with 1 staff member in the four-year old classroom at approximately 11:30am. Upon inquiry by the LI, the staff member apologized and reported that she had notified other Center staff that she had 11 children in her care that morning. The children were observed washing their hands and preparing for lunch, after the children were seated with their lunches at two tables, an extra staff member came into the classroom. The responsible staff member asked that staff person to sit with one of the two groups. After lunch, a child was moved to the three-year old classroom. Plan of Correction: The PD will monitor attendance in each classroom to ensure ratio counts are met each day.
Standard #: 22VAC40-185-440-L Description: Based on observations made by the LI, the Center failed to ensure filled comforters were not used by children under two years of age. Evidence: The LI observed a thick, soft blanket spread across the entire mattress surface of an infant's crib, the infant is under four months old. The edges of the blanket were folded over to the inside of the crib. Upon inquiry, staff reported that the parent had provided the blanket for extra padding under the infant. Plan of Correction: Staff will remove the blanket from the crib and will return the blanket to the infant's parent.
Standard #: 22VAC40-185-450-C Description: Based on interviews with staff, all sheets on infant cribs are not washed daily. Evidence: The LI observed several crib sheets with small stains. Upon inquiry by the LI, staff reported crib linen is sent home on Fridays for the parents to wash and return. Plan of Correction: The PD will notify responsible staff to change and wash all crib sheets daily.
Standard #: 22VAC40-185-500-B Description: Based on the LI's observations, the Center staff failed to ensure the diapering surface was cleaned with soap and water and sanitized after each use. Evidence: The LI observed staff in an infant room (classroom 2) during afternoon diapering procedures. The staff failed to clean and sanitize the diapering surface after changing an infant and before another infant was placed on the surface and changed. Plan of Correction: The PD will review diapering procedures with all responsible staff.
Standard #: 22VAC40-185-510-A Description: Based on reviewed documentation, Staff failed to administer nonprescription medication in accordance to the Center's written medication policies: For nonprescription medication: consistent with the manufacturer's instructions for age, duration and dosage. Evidence: Reviewed documentation in the record of child 7 indicated an over-the-counter medication was administered to a 15 month old child by staff on two different occasions in December, 2015. The manufacturer's instructions indicate to consult with a physician for children under two years old. There was no documentation of a signed physician's order. The parent had given written authorization for short term administration. Plan of Correction: The Program Director will review procedures for administering OTC medications with all responsible medication trained staff (MAT). A written reminder will be placed in the binder for OTC products.
Standard #: 22VAC40-185-510-L Description: Based on reviewed documentation of a medication record for a child in care, the Center failed to administer a prescribed medication as authorized by the child's parent and physician. Evidence: The LI observed a prescribed medication and reviewed the written medication authorization for child b. The medication was to be administered daily at 3:00pm. The medication record did not indicate the medication was administered consistently every week day. The record did not indicate the medication was given from 02/19/16 to 03/01/16. The PD verified that the Center was closed due to inclement weather on February 15 and 16th. The child was not marked absent from the center on days the medication was not administered which included 8 consecutive days. Plan of Correction: The Program Director will review medication procedures with all responsible staff. The medication record will be set up Monday to Friday of each week. If the medication is not given, staff will record on the medication record the reason the medication was not given. The PD will review the incident with the responsible staff and the child's parents will be informed.
Standard #: 22VAC40-191-40-D-1-B Description: Based on a sample review of staff records, the Center failed to obtain a verified background check for an employee before 30 days of employment at the facility ends. Evidence: Two of seven reviewed staff records did not contain documentation of the required background checks. 1. Documentation of a verified Search of the Central Registry was not in the record of Staff #7 whom was employed in the Center in October, 2015. A document was reviewed that indicated the form was submitted and returned to the Center in August, 2015 which indicated incomplete. 2. Documentation of a verified VA State Police criminal record check was not available for review for staff 6, whom was employed in the Center on 02/08/16. Plan of Correction: Staff will not continue to work with the children until a verified background check is received. The PD will check with the appropriate agency and will submit another request.
A compliance history is in no way a rating for a facility.