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

Current Inspector: Barbara Workman (540) 430-9257

Inspection Date: Dec. 7, 2017

Complaint Related: No

Areas Reviewed:
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 children's records, formula feeding schedules, medication, diaper disposal, storage of used linen, injury records and out-of-state central registry checks. The risk assessments for violations were provided. We reviewed safe diapering procedures.

Thank you for your assistance during today's unannounced monitoring inspection conducted from 10:55 AM to 5:20 PM. Today, there were eighty children, ages infancy through five years, with sixteen to seventeen staff. I viewed staffing, program activities, supervision, interactions with children, infant care and records, diapering procedures, daily routines, posted information, agency reports, injury records, emergency supplies and drill records, medication, eight records for children, ten staff records, staff training, staff qualifications, indoor and outdoor areas. The children have enjoyed walks in the neighborhood and outdoor play. Staff were observed providing attentive supervision and responding to children's needs for care and attention. Seasonal activities, including art, stories and discussions, have been provided. Let me know if you need any assistance. 540/430-9259

Standard #: 22VAC40-185-140-A
Description: Based on a review of eight records for children, and an interview with administrative staff, there was not a physical examination record in the file of child 5 that was due within one month after initial attendance. Evidence: Child 5 began attending on September 11, 2017 and there was only an immunization report.

Plan of Correction: The director will request and obtain a copy of the physical examination record for child 5. The director or assigned administrative staff will request the physical examination record from parents at the time of enrollment and use a reminder system for tracking and obtaining the required record within the first month of attendance.

Standard #: 22VAC40-185-500-B
Description: Based on observations in the two infant rooms, and interviews with staff, the requirements for the disposal and storage of used diaper and wipe disposal and the storage of used linens were not followed. Evidence: The foot pedal for opening the disposal container during diaper changes was in disrepair and staff needed to hand lift the lid. During a diaper change in the older infant room, the staff person was lifting the lid by hand and not using the foot-pedal consistently. In the older infant room, an open container without any lining had used linens. Staff indicated that the container had laundry from the previous day as well as this date.

Plan of Correction: The director or designated administrative staff will review the requirements for diapering disposal with all staff who change diapers. A replacement for the diaper disposal container will be obtained for the younger infant room. The director will remind staff to inform the administrative staff whenever equipment breaks and the teachers will always communicate the need to replace equipment. A lined and covered container will be provided for used linen in the older infant room. Procedures for removing laundry from the classrooms will be followed so it does not accumulate. Administrative staff will conduct regular observations of the infant care areas to ensure that all procedures are followed.

Standard #: 22VAC40-185-510-C
Description: Based on a review of medication for two children, and an interview with administrative staff, the center failed to follow procedures to prevent the use of outdated medication. Evidence: An emergency medication kept on hand for child 2M expired in October 2017. Staff indicated that a replacement for the medication had not been arranged with the parent.

Plan of Correction: The administrative staff will return the expired medication or properly dispose of the medication. The parent will be asked to provide a current prescription for child 2M. A designated administrative staff person or M.A.T. certified staff person will keep track of expiration dates of medication so that any needed medication is replaced in a timely manner.

Standard #: 22VAC40-185-550-M
Description: Based on a review of injury records during recent weeks, and an interview with administrative staff, there was required information missing from injury reports viewed from November 2017. Evidence: The serious injury report for November 22, 2017 did not have the time of initial notice to a parent written on the record. There minor injury reports completed on November 6, 2017 and November 22, 2017 that had incorrect information about the date and time of parent notification.

Plan of Correction: The director will meet with staff and review the licensing requirements for documenting the time, date and method of initial notification to parents when injuries are sustained and treated at the center. The director will review the injury reports as soon as possible after each incident and make sure the reports are complete before they are filed.

Standard #: 22VAC40-185-570-C
Description: Based on a review of feeding schedule records completed by parents for infants fed formula at the center, and interviews with staff, there was required information missing for infant 1F, 2F and 3F. Evidence: There was not a feeding schedule form located by staff for infant 1F. The feeding schedules for infant 2F and 3F did not include the brand of formula specified by the parent for feeding.

Plan of Correction: The director will work with the infant room staff to add the type of formula in writing to the schedule forms used for infant 2F and 3F. Also, staff will request and obtain a copy of infant feeding schedule form from the parent of infant 1F. The administrative staff who accept the enrollment paperwork from parents will make sure the infants who will be fed formula have all required information in writing. The infant teachers will make sure the current information about the brand of formula is maintained in writing from the parents and available to all caregivers.

Standard #: 63.2-1721.1-D
Description: Based on a review of ten records for staff, and an interview with administrative staff, the center administration failed to obtain out-of-state child abuse and neglect registry checks for staff who have resided in another state in the preceding five years. Evidence: According to written information in the record and the knowledge of administrative staff, staff member 9 and 10 have lived in a state outside of Virginia. Administrative staff indicated that they did not request information from the applicable state.

Plan of Correction: The director will follow the directions in the Adam Walsh Child Abuse and Neglect registry request information and obtain the required information from the states where staff member 9 and 10 have lived. The director will make sure the out-of-state registry checks are conducted for new and existing staff who have lived outside of Virginia in the past five years


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. To find programs participating in Virginia Quality, click here.

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