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: Sept. 21, 2021 and Sept. 29, 2021

Complaint Related: No

Areas Reviewed:

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

Comments:

A monitoring inspection was initiated on September 21, 2021 and concluded on September 29, 2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 5. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed five staff records, one resident record, fire drills, menus, fire and sanitation inspections, a medication administration record, case management notes, and daily progress notes submitted by the facility to ensure documentation was complete. The on-site portion of the inspection was conducted on September 29, 2021. An exit meeting was conducted with the administrator on this same date, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-151-220-A-4
Description:	Violation: Based on a review of the Program Supervisor job description and interview with administrator A1, the stated qualifications are not in compliance with the minimum requirements of the Child Care Supervisor position. Findings: 1. The education and experience required by the Program Supervisor job description does not meet the education and experience required by the regulation for the Child Care Supervisor position. 2. A1 acknowledged that the education and experience required by the job description did not meet the education and experience required by the regulation for Child Care Supervisor.
Plan of Correction:	A1 provided updated resume for S1 which documented past work experience which meets standard. In the future, A1 and Human Resources will ensure that all applicants under consideration for employment meet the qualifications as required by the regulation prior to offering employment.
Standard #:	22VAC40-151-240-B-2
Description:	Violation: Based on review of the personnel record for staff S1 and interview with administrator A1, S1's full employment history was not documented in the personnel record. Findings: 1. Review of the employment application and resume did not document the full employment history for S1. 2. A1 acknowledged that the employment application and resume did not document all of S1's employment history.
Plan of Correction:	A1 will submit the position titles and descriptions from Standards for Licensed Children?s Residential Facilities to CCC Human Resources. In the future , Human Resources will check to make sure the candidate meets licensing requirements. 10/5/21 A1 will look at all current job positions at Children?s shelter and match them to specific jobs identified in SDSS standards
Standard #:	22VAC40-151-640-A
Description:	Violation: Based on review of the face sheet for resident, R1, and interview with administrator A1, the face sheet was not complete. Findings: 1. The face sheet for R1 did not include religious preference. 2. A1 confirmed that this required element was missing from the face sheet.
Plan of Correction:	Not available online. Contact Inspector for more information.