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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. 28, 2016

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.
22VAC40-191 Background Checks (22VAC40-191)

Comments:
An unannounced renewal inspection was conducted on 10/17/2016. There were 34 children total in care with nine staff present. The inspectors arrived at 6:50 AM. and departed the program at 12:00 P.M. The inspector reviewed five children's and nine staff's records during the inspection. All policies and procedures were reviewed and a building walkthrough was conducted inside and outside. Children were observed during: arrival, morning snack, outside time, quiet activities, and play time. Discussion with site director and director about: using the work study students as staff unless a complete records is obtained, labeling all food in the infant area, sanitizing table prior to eating, ensure that all staff that are a program lead is only supervising two staff. and program lead qualifications.

Violations:
Standard #: 22VAC40-185-40-E
Description: Based on review of records and observation, the center failed to up hold its operational responsibility to ensure compliance with the standards. Evidence: 1. The licensee failed to ensure compliance with standards that are required to maintain a license. This is evident by the citation of 19 violations, of which six were repeat violations proving systemic deficiency.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-60-A
Description: Based on review of five children's records, the center failed to ensure that all records were complete. Evidence: 1. The inspector found that child # 1 did not have a physician or phone number completed.

Plan of Correction: Not available online. Contact Inspector for more information.

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

Evidence:
1. The inspector found that staff # 8 did not have the two required references. Start date for staff # 8 is 5/9/2015.

2. The inspector found that there was no date of hire documented in the staff record for staff person # 10, therefore the LI was unable to determine compliance with staff development and record requirements during this inspection.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-240-B
Description: Based on review of staff policies and procedures, the center failed to ensure that each staff received all required procedures in writing. Evidence: 1. The inspector found and verified through interviews with staff # 13 that all required procedures were reviewed during orientation, but were not given to staff in writing.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-270-A
Description: Based on observation of the building, 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. In the three year old room, the white cabinet has a splintering corner with sharp pieces that pose a hazard to the children in care.
2. In the two year old room, the diaper changing table was missing a knob to the door and has the screw protruding out.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-280-D
Description: Based on observation of the preschool rooms, the center failed to ensure that all chemicals were not stored with single service articles.

Evidence:
1. The inspector found in the three year old room that chemicals were stored with cups and over food/drink.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-340-D
Description: Based on observation and review of nine 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 # 1 did not have the qualifications to be program lead and was observed on the day of the inspection in the infant room from 7: 30 A.M. to 9 A.M. and then in the preschool room from 9A.M. to 12:30 P.M. serving as program lead.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-420-E-3
Description: Based on review of five children's records, the center failed to ensure that all records had an annually update. Evidence: 1. The inspector found no documentation to support an annual review of the record for child # 5 enrolled on 10/20/2014.

Plan of Correction: Not available online. Contact Inspector for more information.

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 out of two pacifiers that were not labeled with the child's name.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-450-C
Description: Based on interviews with infant room staff and observation of crib sheets, the center failed to ensure that all infant crib sheets are washed daily. Evidence: 1. The inspector observed food and other debris on the four crib sheet that were currently being used during the inspection. The inspector verified through interviews with the program lead Staff # 5 that sheets are washed on Mondays and Fridays of each week.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-500-A
Description: Based on observation in the infant 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: Not available online. Contact Inspector for more information.

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 infant room teacher # 12 changing diapers and did not sanitize the changing table after each use when changing two diapers. The changing table was cleaned with a detergent. 2. The two year old room did not contain a disposal system that was either foot operated or used in such away that neither the staff member's hand or the solid diaper touches an exterior surface of the storage system during disposal. The lid was not working on the day of the inspection.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-510-E
Description: Based on observation and review of medications, the center failed to ensure that all requirements for prescription medications were met. Evidence: 1. The inspector found medication for child # 7 that did not have a prescription pharmacy label on the medication and was not accompanied by a prescription label.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-550-E
Description: Based on review of the evacuation drill log, the center failed to ensure that all drills were documented. Evidence: 1. The inspector found that the most recent drill documented was July 2016. A monthly evacuation drill is required to be conducted and documented on the log.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-560-G
Description: Based on observation of the infant room, the center failed to ensure that when food is brought from home that is is labeled and dated. Evidence: 1. The inspector found a container of infant powder formula that was brought from home that was not dated.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-185-560-K
Description: Based on observation of the infant room, the center failed to ensure that the table was sanitized prior to use for meals and snacks. Evidence: 1. The inspector observed the infants eating breakfast and the tables were not sanitized prior to eating.

Plan of Correction: Not available online. Contact Inspector for more information.

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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