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Norfolk Academy Before and After School Programs
1585 Wesleyan Drive
Norfolk, VA 23502
(757) 461-2223 (5716)

Current Inspector: Trisha Brown (757) 404-2601

Inspection Date: Dec. 14, 2017

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.
22VAC40-80 THE LICENSING PROCESS.
63.2 Licensure and Registration Procedures
63.2 Facilities and Programs..
22VAC40-191 Background Checks (22VAC40-191)

Technical Assistance:
Technical assistance was provided in the following areas: 22VAC40-185-(2)-60-A (Children's records); 22VAC40-185-(2)-70-A (Staff records); 22VAC40-191 (Background checks)

Comments:
An unannounced monitoring inspection was conducted on 12/18/17 from 10:20am - 1:30pm. During the inspection there were 55 children ages 5 years old to 12 years old in care with ten staff. A tour of the facility was conducted and children were observed in various classroom activities, playing outside, eating lunch, and during rest period. Records were reviewed for five children and six staff. Medication, emergency procedures, and emergency supplies were reviewed. Areas of non-compliance are identified on the violation notice, and were discussed during the exit interview.

Violations:
Standard #: 22VAC40-185-160-A
Description: Based on a review of nine staff records, it was determined that the facility did not ensure that each staff member submits documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted no later than 21 days after employment or volunteering and shall have been completed within 12 months prior to or 21 days after employment begins. Evidence: 1. The record for staff #3 (date of hire 9/10/17) did not contain documentation of a negative TB screening. 2. The record for staff #5 (date of hire 8/25/17) did not contain documentation of a negative TB screening. 3. The record for staff #9 (date of hire 10/2/17) did not contain documentation of a negative TB screening. 4. Staff #1 (Program Director) reviewed the record for staff #3, staff #5 and staff #9, and confirmed that there was no documentation of a negative screening available for viewing during the inspection.

Plan of Correction: The facility responded: Staff #3, staff #5, and staff #9 will get a TB screening completed. All new staff will complete a TB screening within 21 days of employment or have a TB screening that was completed within the last 12 months.

Standard #: 22VAC40-185-70-A
Description: Based a review of nine staff records, it was determined that the facility did not ensure that they maintain and keep at the center a complete record for each staff that contains all required information. Evidence: 1. The record for staff #3 only contained documentation that one reference as to character and reputation as well as competency was checked before employment. 2. Staff #1 (Program Director) confirmed that the records for staff #2 and staff #7 were not complete.

Plan of Correction: The facility responded: A second reference will be completed for staff #1 and staff #7. New staff will not be allowed to begin employment until their records are complete.

Standard #: 22VAC40-185-340-D
Description: Based on observation, interviews and a review of staff records, it was determined that the facility did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present. Evidence: 1. There were three staff working in the library with 35 school age children when the Licensing Inspector entered the facility. 2. When staff #1 (Program Director) was asked who the Program Leader was for this grouping of children, he stated that all three staff were not qualified as a program leader, and were only Program Assistants. Staff #1 stated two program leaders called out from work on the day of the inspection.

Plan of Correction: The facility responded: Two staff called out on the day of the inspection, so the usual staff were not present. We will ensure to place documentation in each file of how that staff is qualified for the position. Center management will ensure that there is at least one Program Leader in each grouping of children.

Standard #: 22VAC40-191-60-B
Description: Based on a review of nine staff records, it was determined that the facility did not ensure that all employees have completed a sworn statement or affirmation prior to employment. Evidence: 1. Staff #1 (date of hire 8/25/17) did not contain documentation of a completed sworn statement or affirmation. 2. Staff #2 (date of hire 8/25/17) did not contain documentation of a completed sworn statement or affirmation. 3. Staff #6 (date of hire 8/25/17) did not contain documentation of a completed sworn statement or affirmation. 4. Staff #7 (date of hire 8/25/17) did not contain documentation of a completed sworn statement or affirmation. 5. Staff #9 (date of hire 8/25/17) did not contain documentation of a completed sworn statement or affirmation. 6. Staff #6 (date of hire 8/25/17) did not contain documentation of a completed sworn statement or affirmation. 7. Staff #1 (Program Director) reviewed the record for staff #1, staff #2, and staff #7, and confirmed that it was not the correct version of the sworn statement or affirmation in any of the

Plan of Correction: The facility responded: All staff who completed the older version of the sworn statement of affirmation will complete the correct version.

Standard #: 22VAC40-191-60-C-1
Description: Based on a review of nine staff records, it was determined that the facility did not deny continued employment of a staff who did not have an original criminal history record report within 30 days of employment. Evidence: 1. The record for staff #3 (date of hire 9/10/17) did not contain documentation of a an original criminal history record report. 2. Staff #1 (Program Director) confirmed that the criminal history record report has not been received for staff #3.

Plan of Correction: The facility responded: A criminal record check was requested for staff #1. We will call the Virginia State police to check the status of the request.

Standard #: 22VAC40-191-60-C-2
Description: Based on a review of seven staff records, it was determined that the facility did not deny continued employment of a staff who did not have a search of the central registry finding within 30 days of employment. Evidence: 1. The record for staff #3 (date of hire 9/10/17) did not contain documentation of a completed search of the central registry finding. 2. Staff #8 (Program Director) confirmed that the search of the central registry finding has not been received for staff #2, and staff #7.

Plan of Correction: The facility responded: A new search of the central registry for each staff was mailed. when they were hired. We will call the Virginia Department of Social Services to check the status of the request.

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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