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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: June 27, 2016

Complaint Related: No

Areas Reviewed:
22VAC40-191 Background Checks (22VAC40-191)

An unannounced non mandated monitoring inspection was conducted on 6/27/2016. There were 43 children total in care with eight staff present. The inspector arrived at 11: 00 A.M. and departed the program at 2:30 P.M. The inspector reviewed two children's and six staff's records during the inspection. A building walkthrough was conducted inside and outside. Children were observed during: outside play, inside play time, lunch, and nap. Discussion with site director and director about: using the work study students as staff unless a complete record is obtained, and the new office staff attending Phase 2 training in the Licensing Office.

Standard #: 22VAC40-185-160-C
Description: Based on review of six staff's records, the center failed to ensure that all repeat TB screenings were completed every two years. Evidence 1. The inspector found that staff # 2 TB was not within the required two year time frame. The previous TB screening was completed on 5/5/2014 with the most recent TB screening completed on 6/1/2016.

Plan of Correction: Staff member had remarried, was waiting on documents with new name to have test. Was Completed and is in file. A ?ticker file? is being developed to help remind staff who need to have updated information.

Standard #: 22VAC40-185-70-A
Description: Based on review of six staff records, the center failed to ensure that all records were complete. Evidence: 1. The inspector found that staff # 1, 3 and 5 did not have the two required references. Start date for staff # 1 is 3/2/2015, start date for staff # 3 is 9/29/2015 and start date of staff # 5 is 6/14/2016.

Plan of Correction: References have been contacted, comments noted and dated by the office administrator and will be monitored by the director.

Standard #: 22VAC40-185-270-A
Description: Based on observation of the playground area, the center failed to ensure that all areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. Evidence: 1. The inspector found that the plastic climber had cracks on the yellow portion of the climber that could pose a pinching hazard to the children in care.

Plan of Correction: During the inspection the staff removed and discarded the climber.

Standard #: 22VAC40-185-330-B
Description: Based on observation of the playground, the center failed to ensure that the require amount of resilient surfacing was on the playground. Evidence: 1. The inspector observed that the immediate fall zone of the climber on the upper playground did not have the required six inches of pea gravel. The pea gravel was less than 1 inch in depth in various areas in the fall zone.

Plan of Correction: During the inspection the climber was removed from the playground. Climbing toys were removed. Toys requiring a fall zone will not be allowed in the future, since we are unable to maintain the required amount of surfacing.

Standard #: 22VAC40-185-340-D
Description: Based on observation and review of six staff's records, the center failed to ensure that all groupings of children had a qualified program lead. Evidence: 1. The inspector found that staff # 6 did not have the qualifications to be program lead and was observed on the day of the inspection in the two year old classroom as program lead.

Plan of Correction: The teacher in question has been with the school for some time and has more than adequate qualifications. However, her file was out of place on the day of inspection. The file is now in its? proper location and contains all necessary evidence of the require qualifications.

Standard #: 22VAC40-185-480-B
Description: Based on interviews and review of children's records, the center failed to ensure that all children that participate in swimming or wading had written permission from the parent. Evidence: 1. On the day of inspection the inspector observed the Pre-K class wadding in plastic swimming pools. Determined through interviews and review of children's records the children did not have written permission from parents to participate. The teacher notified all parents prior to the water day, but written permission was not obtained.

Plan of Correction: Wading pools have been disposed of. Water play will now only consist of water tables, to avoid not having the required permission each time.

Standard #: 22VAC40-185-500-A
Description: Based on observation in the two year old room, the center failed to ensure that all children washed their hands after toileting process. Evidence: 1. The inspector observed a child in the process of a diaper change. The child did not wash their hands after having their diaper changed.

Plan of Correction: Staff has been reminded to be sure all hands are washed after diapering and be observed to ensure this happens. Monitored by the site director.

Standard #: 22VAC40-185-500-B
Description: Based on observation of diapering time, the center failed to ensure that all diapering requirements were followed. Evidence: 1. The inspector observed the two year old teacher changing a diaper and did not sanitize the changing table after use. The changing table was cleaned with soap and water. 2. The down stairs bathroom did not contain a disposal system that was either foot operated or used in such away that neither the staff member's hand not the solid diaper touches an exterior surface of the storage system during disposal. Determined through interviews with staff there are two children that require diapering that use the down stairs bathroom.

Plan of Correction: Teacher will review the requirements for sanitizing and will be observed on occasion to ensure all steps are being covered

Standard #: 22VAC40-185-540-C
Description: Based on observation of the center and bus, the center failed to ensure that all required items were in the first aid kits. Evidence: 1. The inspector found that the downstairs first aid kit was missing the following: antiseptic cleansing solution or pads, two triangular bandages adhesive tape and gauze pads. 2. The bus's first aid kit was missing: ice pack or cooling agent, and adhesive tape.

Plan of Correction: Required items have been placed in both kits. Note: One was not a kit we normally use and the bus kit had been inspected by licensing previously and the items cited at that time had been added.

Standard #: 22VAC40-185-560-F
Description: Based on observation, the center failed to ensure that a menu was posted in a location conspicuous to parent or given to parents. Evidence: 1. The monthly menu was posted in the kitchen. The kitchen is not accessible to the parents.

Plan of Correction: Menu is now posted weekly. Note: Previous staff had neglected to post the menu and train new staff of this policy.

Standard #: 22VAC40-80-120-E-1
Description: Based on observation the center failed to ensure that the most recent license was posted by the public entrance. Evidence: 1. The most recent Provisional License was not posted.

Plan of Correction: The license is now posted. Note: The new license had just arrived, after we had called about it earlier in the week. We needed to fax a copy to a new client/provider, but we were waiting on the fax number.

Standard #: 22VAC40-80-120-E-2
Description: Based on observation, the center failed to ensure that the most recent violation notice was posted. Evidence: 1. The inspector found that the violation notice from 11/2014 was posted rather than the most recent inspection that was completed on 3/29/2016

Plan of Correction: The violations are now posted: Note: Office staff was working on the improvement plan for the new violations and had neglected to post a copy.


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.