Community Fellowship Church of the Nazarene

22.1-289.035-B-4

“SYSTEMIC DEFICIENCY The exempt program is required to obtain background checks from any state in which the individual has resided in the preceding five years. Staff 5, who has been employed for more than four months, did not have documentation of requesting a central registry check and no documentation of a sex offender check from a different state.”

22.1-289.035-A

“SYSTEMIC DEFICIENCY The exempt program is required to have employees undergo a background check every five years. The most recent national criminal background check for Staff 1 was overdue by two years and one month. The most recent sworn disclosure statement for Staff 1 was overdue by three years and seven months.”

22.1-289.035-B-3

“SYSTEMIC DEFICIENCY The exempt program must request a search of the central registry prior to the employee's first day of employment. Staff 5, employed for more than four months, did not have documentation of requesting a central registry search requested. Staff 7, employed for more than nine months, did not have documentation of a central registry search requested.”

22.1-289.031-B-4

“The center must develop and implement a procedure to ensure that all children in the center are in compliance with provisions regarding the immunization of children. Child #3 did not have updated immunizations in record.”

22.1-289.031-A-4

“Each person in a supervisory position has been certified by a practicing physician or physician assistant to be free from any disability which would prevent him from caring for children under his supervision. Staff # 6 does not have documentation in their file stating that they are free from any disability which would prevent him from caring for children under his supervision.”

22.1-289.031-B-5

“Based on a review of the staff handbook and interview, the center failed to establish and implement a procedure to ensure that all areas of the premises accessible to children are free of obvious injury hazards, including providing and maintaining cushioning material under playground equipment. Evidence: 1. In the Caterpillar room there was Clorox wipes on top of the low cabinet in the bathroom used by children. 2. In the Kangaroo room there was Lysol wipes on a low shelf. 3. The center's policy is for hazardous substances to be kept out of reach of children. 4. On the school age playground there was exposed ground covering and no mulch under the monkey bars.”

8VAC20-770-40-D-2

“Based on record review and interview, the center failed to have staff sign a sworn disclosure statement prior to the first day of employment and have a completed central registry record check by the end of the 30th day of employment. Evidence: Staff 2, first day of employment 2/1/18, and staff 3, first day of employment 2/21/22, do not have a central registry background check in their file. Staff 6, first day of employment 3/27/23, did not have a sworn statement in their file.”

22.1-289.035-A

“Based on record review and interview, the center failed to update background checks every 5 years. Evidence: Staff 2 has a fingerprint background check dated 04/08/2019.”

22.1-289.035-B-4

“Based on record review and interview, the center failed to request a search of central registry background check within the first 30 days of employment and a search of sex offender registry prior to the first day of employment. Evidence: 1. The record for staff 1 was reviewed. The record document the employment date as 11/16/22. Per the resume for staff 1 in the file up until the hire 2022 staff 1 worked in NJ. The record for staff 1 did not contain a central registry background check or sex offender search for NJ. 2. The director verified they did not complete an a central registry background check or sex offender search for NJ.”

22.1-289.031-B-4

“REPEAT VIOLATIONS Based on record review and interview, the center failed to implement a procedure to ensure all children in the center are in compliance with immunization provisions for two out of three children's records reviewed. Evidence: 1. The record for child 1 documents the start date as 2/10/22. There was no immunizations in the record. 2. The record for child 3 documents the start date as 11/19/22. There was no immunizations in the record. 3. The center's policy is that immunizations are due prior to the first date of attendance per the parent handbook.”

22.1-289.031-B-4

“Based on a record review, the center failed to implement the center procedure to ensure all children in the center are in compliance with immunization provisions to obtain a copy of children's immunizations records prior to the first date of attendance. Evidence: Child 2's first date of attendance is documented as 8/10/21. The immunization records are dated 11/18/21.”

22.1-289.031-A-4

“Based on record review and interview, the center failed to ensure all staff have been certified by a practicing physician or physician assistant to be free from any disability which would prevent him/her from caring for children under his/her supervision prior to start date. Evidence: 1. Staff 1's start date is documented as 7/7/21. Staff 1 has not provided documentation of being certified by a practicing physician or physician assistant to be free from any disability which would prevent him/her from caring for children. 2. Staff 3's start date is documented as 11/22/21. The staff health report for staff 2 is dated 12/3/21.”