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Braddock Street United Methodist Early Learning Center
103 South Braddock Street
Winchester, VA 22601
(540) 667-8915

Current Inspector: Barbara Workman

Inspection Date: March 28, 2017

Complaint Related: No

Areas Reviewed:
32.1 Report by person other than physician
63.2 General Provisions.
63.2 Child Abuse and Neglect
63.2 Licensure and Registration Procedures
63.2 Facilities and Programs..
22VAC40-191 Background Checks (22VAC40-191)

Technical Assistance:
We discussed the requirements for immunization reports, background checks, and "tummy time" for young infants. The risk assessments for violations were provided. Also, we talked about procedures for spoon feeding infants. The food may be directly fed from the original container only if all contents will be used or leftovers are discarded. Otherwise, placing some of the food with an unused utensil into a clean dish and then feeding from the dish is the required method to avoid children eating leftover food that was contaminated by a used spoon and the possible growth of bacteria in that food that would be used later if sent home or re-used by the center. We reviewed documentation that can be used to verify education qualification requirements such as school diplomas or transcripts. These must be maintained in the staff files.

Thank you for your assistance during today's unannounced renewal inspection conducted from 11:00 AM to 4:52 PM. Today, there were seventy-five children, ages infancy through five years, with fourteen to fifteen staff. I viewed program activities, supervision, staffing, interactions with children, equipment, posted information, sanction compliance, infant care and records, diapering procedures, daily routines, lunch/snack, five records for children, five staff records, staff qualifications, staff training, sunscreen requirements, diaper ointment, walking field trip requirements, injury records, emergency supplies and drill records, business entity records, indoor and outdoor areas. The children were provided access to age appropriate toys and materials. There have been learning opportunities based on planned themes such as preschool children learning about different continents and countries. Art experiences, sensory experiences, stories and music have been regularly provided. The additions on the playground at the new deck area were viewed. Infants have been taken to the grassy lot which has a wall by the church ally for outdoor experiences. Issuance of the renewed license will be recommended after the required background checks for the application process are received and viewed. Let me know if you need any assistance. 540/430-9259

Standard #: 22VAC40-185-130-B
Description: Based on a review of five records for children, and an interview with administrative staff, there were not updated immunization records for child 3 and 5 that were required once every six months for children under the age of two years. Evidence: The only immunization report in the file for child 3, age seventeen months, was completed August 2, 2016. The only immunization report in the file for child 5, age sixteen months, was completed July 1, 2016. The director checked with other staff and there were no other immunization reports obtained.

Plan of Correction: The director and administrative staff assigned to the oversight of children's records will make sure the updated immunization reports are requested and obtained. Administrative staff will review all records of children under age two during the past year and make sure all updated immunization reports have been obtained and filed. A system for tracking the record update needs for children will be used to make sure all updated immunization reports are obtained in a timely manner.

Standard #: 22VAC40-185-370
Description: Based on observation of the daily activities for infants, a review of the documentation on infant daily sheets and interviews with staff, the required tummy time for infants, who cannot turn themselves over and are awake, has not been provided 30 minutes each day to facilitate upper body strength and to address misshapen head concerns. Evidence: During observations at 11:45 AM and 1:45 PM, the awake youngest infants were observed in infant seats or on their backs on the floor when they were not sleeping or held for feeding. The daily sheet for infant 1T who attended morning hours only this date did not have any documented tummy time. Infant 2T arrived at 8:15 AM and there was no documented tummy time by noon. Infant 3T arrived by 8:30 AM and there was no documented tummy time. The caregiver staff interviewed during the day indicated that awake infants who do not roll over on their own have not always been placed on their stomachs for intervals of time as required and documentation of tummy time has not been attended to by the caregivers.

Plan of Correction: The administrative staff will review with the caregivers the requirement for thirty minutes of tummy time, conducted in shorter intervals of time during awake time activities, and the timely documentation of the activity. The director will revise the daily sheet so that a designated place for documenting tummy time is easily visible and used on the form. Administrative staff will conduct periodic checks of the documentation of tummy time on the daily sheets and conduct observation of infant care activities/routines to ensure compliance with the minimum standards.

Standard #: 22VAC40-191-40-D-1-A
Description: Based on a review of two business entity representative records, five staff records, and an interview with administrative staff, the background checks for business entity representative 1 was not obtained within thirty days of the start date. Evidence: Business entity representative 1 began in her position on February 23, 2017 during a position change decision at a meeting. The sworn statement or affirmation was not signed until March 8, 2017 at the time the request forms for the criminal record history and the central registry check were completed. The criminal history check and the central registry clearance have not been received for the records.

Plan of Correction: The director will make follow-up phone calls to the agency in Richmond to check on the process of the requested background checks. In the future, the director and business entity representatives will make sure the sworn statements are signed at the time of position changes and the requests for the background checks will be sent within the first week of the changes. If background checks are not received within thirty days, the director or other representative will contact the agency in Richmond to check on the requests while documenting the efforts to contact the agency.

Standard #: 22VAC40-191-40-D-1-C
Description: Based on a review of two records for business entity representatives, five staff records and an interview with administrative staff, there was not an updated sworn statement or affirmation, criminal history record check and central registry clearance obtained as required before three years since the dates of the last completed reports for business entity 2. (Repeat violation.) Evidence: The most recent sworn statement in the file was signed March 18, 2013. The criminal history record was completed March 26, 2013 and the central registry check was completed April 8, 2013.

Plan of Correction: The director immediately had business entity 2 sign another sworn statement form. The requests for the two background checks will be mailed this week. The director will contact the agencies in Richmond if the background checks are not received within thirty days of the requests. The director will add the business entity record dates to the information used for a reminder system so that records are updated before three years since the last records were obtained.


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.