VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cabrini Children's Center: Commonwealth Catholic Charities
2250 Pump Road
Richmond, VA 23233
(804) 362-0063

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: Jan. 8, 2020 , Jan. 9, 2020 , Jan. 13, 2020 and Jan. 16, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-151 22VAC40-151 III. RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCEY PLANNING

Comments:

An unannounced monitoring inspection was conducted on January 8, 2020 from 9:30 a.m. to 1:45 p.m. Five personnel records, to include background investigation information, were reviewed. No residents were in care at the time of the inspection. Interior and exterior physical plant inspections were conducted. Staff S6 and Staff S7 were available to respond to questions. Preliminary inspection findings were reviewed with Staff S6 and Staff S7 prior to leaving the inspection on January 8, 2020 and an acknowledgement form was signed. Desk audits to review additional documentation were conducted on January 9, 2020, January 13, 2020, and January 16, 2020. Exit meeting was held with Staff S6 via telephone on January 16, 2020. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return to the Licensing Office within 5 business days from receipt of the inspection documentation. You will need to specify how the deficient practice will be or has been corrected (merely writing the word corrected is not acceptable). Your plan of correction must contain the steps to correct the noncompliance with the standard(s), the measures to prevent the noncompliance from occurring again; and the position responsible for implementing each step and/or monitoring any preventive measure(s). The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS web site within 5 days, regardless of whether the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-151-210-B-1
Description:	Violation: Based on review of the personnel record for Staff S4, and interview with Staff S6, S4's resume did not document the minimum experience required by the job description. Findings: 1. Review of the resume for S4 revealed the experience did not meet the minimum experience required by the job description. 2. During an interview with the Licensing Specialist, S6 confirmed that S4's qualifications did not match the minimum experience documented in the job description.
Plan of Correction:	The job description listed the preferred requirements and will be updated to list the minimum set by ORR.
Standard #:	22VAC40-151-240-B-9
Description:	Violation: Based on review of the personnel records for Staff S3 and S5, the training record was not documented in the personnel records. Findings: 1. The training record was not documented in the personnel records for S3 and S5. 2. During an interview with the Licensing Specialist, Staff S7 confirmed that while the initial training had been completed, it was not documented in the personnel record at the time of the inspection.
Plan of Correction:	The training records have been updated so that candidates can sign and turn in training logs at week one, two, three and four. This will ensure that completed trainings will be placed in the respective personnel file in a timely manner.