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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: April 19, 2018

Complaint Related: No

Areas Reviewed:
32.1 Report by person other than physician
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 supplies, background checks, medication, storage of hazardous substances, and indoor safety. The risk assessments for violations were provided. We talked about the importance of checking electric outlets and power strips for replacement of protective covers. We talked about making sure the gym area is used with less children when space has been reduced. Also, younger children should be protected from the active movement and play of older children. Also, we talked about plans for coverage by M.A.T. certified staff during staff absences.

Thank you for your assistance during today's unannounced monitoring inspection conducted from 10:45 AM to 4:10 PM. Today, there were eighty-three children, ages infancy through five years, with eighteen staff. While accompanied by a second licensing inspector, we viewed program activities, equipment, staffing, supervision, interactions with children, daily routines, infant care and records, posted information, injury records, emergency supplies and drill records, agency reports, medication, center policy, eight records for children, eight staff records, staff qualifications, staff training, indoor and outdoor areas. The children enjoyed a variety of age appropriate activities and equipment in their assigned areas. Indoor active play was enjoyed in part of the gym. The teachers were observed providing frequent interactions with children and attentive care. Diapering procedures were appropriate. 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, the physical examination record for child 8 was not obtained within the first month of attendance. Evidence: Child 8 began attending on September 11, 2017 and there was only immunization information obtained for the record.

Plan of Correction: Administrative staff asked for the physical examination record and it will be obtained for the record. A new procedure will be implemented requiring parents to sign that they have provided the list of required documents listed or their child will not be able to attend without the required paperwork.

Standard #: 22VAC40-185-40-E
Description: Based on a review of prescription medication at the center, perscription diaper cream, interviews with staff, and a review of center policies, the center staff failed to comply with the center's medication policies. Evidence: There were prescription diaper ointments in the two year old class for child 2M and 3M. Staff indicated they did not have written authorization forms signed by parents and by physician's for long-term use. A hand written note was in a clear bag with the ointment for child 3M and stated to apply the medication ointment and then normal diaper ointment. The hand written note did not have a child's name or parent signature.. Staff indicated there was not a record of application due to staff not applying the diapering medication, yet, the unused medication was not sent home per policy. There was not a prescription label with the ointment tube for child 3M. A staff member indicated that the prescription diaper ointment for child 2M was stored at the center and only used by a parent. However, it was not labeled as for parent use only and sent home daily. Also per the medication policy, the directors have not checked the all medication periodically in each storage area.

Plan of Correction: The diaper ointment for child 2M and 3M will be sent home. The director will review the medication policies with staff and the staff will make sure any diaper prescription medication kept at the center has the required labels, authorization forms and that staff keep track of the need to send unused medications home. A staff member will be assigned to view the diaper ointment stored in each room on a monthly basis and assist staff with center medication procedures.

Standard #: 22VAC40-185-280-B
Description: Based on observation of the classrooms, and interviews with staff, staff in room 117 did not ensure that hazardous substances were stored in a locked place. Evidence: During the late morning, around 11:20 AM, there was a staff person with five children. The wall cabinet door by the changing table was open and contained Great Value disinfectant spray, Great Value disinfectant wipes, Germ-X Hand Sanitizer, Aqua Net spray, Shout spray, Glade Air Spray, and diaper ointment, including two prescription ointments. There were two spray bottles hanging above the toilet from a shelf, including one containing bleach and water spray. Staff indicated that the spray bottles are usually stored in the wall cabinet and the door kept latched.

Plan of Correction: The spray bottles were returned to the cabinet and the cabinet door locking mechanism for child proofing was latched. The director will review with staff the requirements for maintaining hazardous substances in areas that are kept locked after each use.

Standard #: 22VAC40-185-290-3
Description: Based on observation of the indoor areas used for the care of children, and interviews with staff, there were electric outlets that did not have protective covers. Evidence: There were an uncovered wall outlets within reach of children in activity areas in rooms 108, 112 and 117. The staff indicated that the outlets were used in the evening by cleaning staff and not covered after use.

Plan of Correction: The morning teaching staff will check all accessible outlets and make sure they are recovered if left open the night before. The director will remind the staff who use outlets to always recover them.

Standard #: 22VAC40-185-570-I
Description: Based on a review of supplies for infants who are fed commercial formula, and interviews with staff, the center failed to maintain a one-day's supply of commercial formula for four infants in the Infant 2 room. Evidence: When asked about storage of the extra formula, staff indicated that the center provided container of formula kept for possible emergencies had an expiration date of March 2018 and was thrown away two weeks ago. The staff said they did not make arrangements for the purchase of another container of formula. When viewing formula brought from home for four infants, the amounts were not adequate for the required emergency supply.

Plan of Correction: The director arranged for the purchase of another container of emergency supply formula. The director will speak with staff and review the procedures for submitting purchase needs in a timely manner.

Standard #: 63.2-1809-A
Description: Based on a review of eight records for children, and an interview with administrative staff, the center failed to obtain proof of age and identity within seven business days of enrolling child 1 and 7. Evidence: There was not any documentation of birth such as a certificate or hospital information, and the initial attendance date for child 1 was September 5, 2017 and for child 7 was December 4, 2017. Administrative staff did not locate any documentation of the birth records viewed or reporting to law enforcement after seven business days.

Plan of Correction: Administrative staff requested copies of birth records from the parents of child 1 and 7. The administrative staff person who enrolls children and accepts the initial registration forms will make sure parents understand to submit the proof of age and identity such as a birth record or custody information. If the information is not received within seven business days, the director or assigned administrative staff will contact the appropriate law enforcement office and document the call for the child's record.


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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