Disciples of Christ Fellowship Ministries

22.1-289.035-A

“Based on record review, the Center failed to complete Central Registry Background Check within 5 years from the date of the most recent Central Registry Background Check. EVIDENCE: Staff #2 did not have an updated Central Registry Background Check. Most recent Central Registry was completed 9/14/2017.”

22.1-289.031-A-4

“Based on record review, the Center failed to ensure each staff person complete health exam prior to supervising children. EVIDENCE: Records for Staff #1 and Staff #3 did not include documentation of a health exam. Both staff were observed supervising children during the inspection.”

22.1-289.035-B-2

“Based on record review, the Center failed to have Fingerprint Background Check completed for each staff person before date of employment. EVIDENCE: Fingerprint Background Check results for Staff #1 and Staff #2 were unavailable. Date of employment was not documented in each record. Both Staff #1 and Staff #2 were observed working with children during inspection.”

8VAC20-770-40-D-2

“Based on record review, the Center failed to have Sworn Disclosure Background Check completed for each staff person before date of employment; Center failed to have Central Registry Background Check completed for each staff person by the end of the 30th day of employment. EVIDENCE: Sworn Disclosure for Staff #1 and Staff #2 were unavailable. Date of employment was not documented in each record. Both Staff #1 and Staff #2 were observed working with children during inspection. Central Registry Background Check results for Staff #1 and #3 were unavailable. Date of employment was not documented in each record. Staff advised Licensing Inspector that they have worked at the center more than 30 days. Staff #1 and #3 were observed working with children during inspection.”

8VAC20-790-600-C

“Based on record review, the Vendor failed to ensure each staff person completes center orientation training prior to the staff member working alone with children and within seven days of the date of employment. EVIDENCE: 1. Record for Staff #1 did not include documentation on orientation training on the facility specific topics. Staff #1 was observed working on the day of the inspection. 2. Record for Staff #2 did not include documentation on orientation training on the facility specific topics. Staff #2 was observed working on the day of the inspection. 3. Record for Staff #3 did not include documentation on orientation training on the facility specific topics. Staff #3 was observed working on the day of the inspection.”

8VAC20-790-600-D-1

“Based on record review, the Vendor failed to ensure all staff who work directly with children completes CPR certification within 90 days of hire. EVIDENCE: 1. Record for Staff #1 did not include documentation of CPR certification. Licensing Inspector observed Staff #1 working during the previous inspection (9/03/2022). 2. Record for Staff #2 did not include documentation of CPR certification. Licensing Inspector observed Staff #2 working during the previous inspection.”

8VAC20-790-560-A

“Based on record review, the Vendor failed to ensure each staff person is evaluated by a health professional and issued a statement that the individual is determined to be free of communicable tuberculosis (TB) submitted at the time of employment and completed prior to coming into contact with children. EVIDENCE: 1. Record for Staff #1 did not include documentation of a TB test. Staff #1 was observed working on the day of the inspection. 2. Record for Staff #2 did not include documentation of a TB test. Staff #2 was observed working on the day of the inspection. 3. Record for Staff #3 did not include documentation of a TB test. Staff #3 was observed working on the day of the inspection.”

8VAC20-790-540-B

“Based on record review, the Vendor failed to ensure each child’s record included all the requirements per the standard. EVIDENCE: 1. Record for Child #1 did not include the employers name, address, and work phone for Parent/Guardian #1. 2. Record for Child #2 did not include the employers work phone for Parent #1. 3. Record for Child #3 did not include the employers address and work phone for Parent #1 and Parent #2.”

8VAC20-790-530-B

“Based on documentation review, the Vendor failed to maintain a written hard copy record of daily attendance that documents the arrival and departure of each child in care as it occurs. EVIDENCE: Written hard copy of daily attendance was unavailable.”

8VAC20-790-800-A-3

“Based on inspection, the Vendor failed to ensure lockdown procedures are practiced at least annually. EVIDENCE: The provider did not have documentation of an annual lockdown emergency drill.”

8VAC20-790-800-A-2

“Based on documentation review, the Vendor failed to ensure shelter-in-place procedures are practiced twice a year. EVIDENCE: The provider did not have documentation of an annual shelter-in-place drill completed.”

8VAC20-790-790-A

“Based on documentation review, the Vendor failed to have a written emergency preparedness plan. EVIDENCE: An emergency preparedness plan was unavailable.”

8VAC20-790-640-A

“Based on observation, the Vendor failed to keep hazardous substances in a locked place using a safe locking method that prevents access by children. EVIDENCE: Licensing Inspector observed unlocked hazardous cleaning agents at the outside entrance of the center. Agents were accessible to the children in care.”

8VAC20-790-550-1

“Based on record review, the Vendor failed to keep a record containing the date of employment, address, and verification of age for each staff person. EVIDENCE: 1. Record for Staff #1 did not include the date of employment, address, or verification of age. 2. Record for Staff #2 did not include the date of employment, address, or verification of age. 3. Record for Staff #3 did not include the date of employment, address, or verification of age.”

8VAC20-790-630-A

“Based on observation, the Vendor failed to keep areas and equipment of the center, inside and outside in a clean, safe and operable condition. EVIDENCE: The wrought iron handrail on the entrance steps were missing multiple slats on the top platform level (approximately 12 feet from the ground level) creating a fall hazard.”

8VAC20-790-600-I

“Based on record review, the Vendor failed have at least one staff person on duty who has obtained within the last three years instruction in performing a daily health observation of children. EVIDENCE: There were no staff present during the inspection who has received Daily Health Observation of children training.”

8VAC20-790-600-D-2

“Based on record review, the Vendor failed to ensure all staff who work directly with children completes First aid certification within 90 days of hire. EVIDENCE: 1. Record for Staff #1 did not include documentation of First Aid certification. Licensing Inspector observed Staff #1 working during the previous inspection (9/03/2022). 2. Record for Staff #2 did not include documentation of First Aid certification. Licensing Inspector observed Staff #2 working during the previous inspection.”

8VAC20-790-670-C-2 Complaint related: Yes

“Based on inspection, Religiously Exempt day care failed to maintain required adult to child ratios, one staff member to five children, for children ages 16 months to 24 months. EVIDENCE: Licensing Inspector observed 11 children ages 16 months through 2 years old under the direct supervision of 2 staff members. Required adult to child ratios were not maintained.”

8VAC20-790-670-C-4 Complaint related: Yes

“Based on observations, the Religiously Exempt day care failed to maintain required adult to child ratios, one staff member to 10 children, for children 3 to 5 years old. EVIDENCE: Licensing Inspector observed a total of 13 children ages 3 to 5 years old under the direct care of 1 staff member. Adult to child ratios were not maintained.”

8VAC20-790-800-A-1

“Based on inspection, the Vendor failed to practice and document evacuation procedures at least once each month. EVIDENCE: Documentation of the monthly emergency evacuation drills were unavailable.”

8VAC20-790-540-B-12

“Based on record review, the Vendor failed to obtain proof of a child's identity and age. EVIDENCE: Licensing Inspector reviewed 6 children records. Record for Child #5 did not include documentation of proof of identity and age. Child #5 did not have documentation of the 1st day of attendance.”

8VAC20-790-780-C-2

“Based on inspection, the Vendor failed to have required nonmedical emergency supplies. EVIDENCE: A working battery-operated radio was unavailable.”

8VAC20-790-670-E

“Based on inspection, the Vendor failed to develop and implement a written policy and procedure that describes how the vendor will ensure that each group of children receives care by consistent staff or team of staff members. EVIDENCE: Center has not developed a written policy and procedure continuity of care.”

8VAC20-790-650-C-4

“Based on inspection, the Vendor failed to equip the restroom used by the children in care with toilet paper, soap and disposable towels or an air dryer within reach of the children. EVIDENCE: The restroom used by the children was not equipped with toilet paper, soap and paper towels.”

8VAC20-790-630-C-2

“Based on inspection, the Vendor failed to ensure electrical outlets have protective covers. EVIDENCE: The Licensing Inspector observed several electrical outlets that were not protected with protective covers. An uncovered electrical outlet was observed beside a infant's crib (child observed sleeping in the crib) that was accessible to the child through the crib slats. A second uncovered electrical outlet was located beside a child sleeping on a cot.”

8VAC20-790-580-A

“Based on record review, the Vendor failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. EVIDENCE: Licensing Inspector reviewed 6 children records. Records for Child #5 and Child #6 did not include documentation of immunizations. The enrollment date for Child #6 is 9/16/2022. Record for Child #5 did not include the 1st day of attendance.”

8VAC20-790-540-B

“Based on record review, the Vendor failed to have the name, home address and telephone number for each parent who has custody, 1st day of attendance, documentation of immunizations on or before the 1st day of attendance and the name address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached. EVIDENCE: The Licensing Inspector reviewed 6 children records. Record for Child #1, Child #2 and Child #5 did not include the address for each parent who has custody. Records for Children #1, #2, #3 #4 and #5 did not include documentation of the 1st day of enrollment. Records for Children #5 and #6 did not have documentation of immunization records received on or before the child's first day of attendance. Records for Children #5 and #6 did not include the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached.”

22.1-289.031-A-4

“Based on record review & discussion with staff, the Center failed to ensure each staff member 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. EVIDENCE: The Licensing Inspector reviewed 3 staff records. Records for Staff #1 and Staff #2 did not contain documentation of a current staff health report.”

8VAC20-770-40-D-2

“Based on record review, the Center failed to ensure staff, volunteer, or any other person who is expected to be alone with one or more children enrolled in the religious exempt child day center a Sworn Statement or affirmation before employment or commencement of service at the facility and a search of Central Registry within 30 days of employment or commencement of service. EVIDENCE: The Licensing Inspector reviewed 3 staff records. Record for Staff #2 did not contain documentation of a completed Sworn Disclosure or affirmation prior to employment. The hire date was not documented in the record. Records for Staff #1 and Staff #3 did not contain documentation of a completed Central Registry record check before the end of their 30th day of employment. The hire date for Staff #1 and Staff #2 were not identified in their prospective records.”

8VAC20-790-800-A-1

“Based on inspection, the Vendor failed to practice and document evacuation procedures at least once each month. EVIDENCE: Documentation of the monthly emergency evacuation drills were unavailable.”

8VAC20-790-540-B-12

“Based on record review, the Vendor failed to obtain proof of a child's identity and age. EVIDENCE: Licensing Inspector reviewed 6 children records. Record for Child #5 did not include documentation of proof of identity and age. Child #5 did not have documentation of the 1st day of attendance.”

8VAC20-790-780-C-2

“Based on inspection, the Vendor failed to have required nonmedical emergency supplies. EVIDENCE: A working battery-operated radio was unavailable.”

8VAC20-790-670-E

“Based on inspection, the Vendor failed to develop and implement a written policy and procedure that describes how the vendor will ensure that each group of children receives care by consistent staff or team of staff members. EVIDENCE: Center has not developed a written policy and procedure continuity of care.”

8VAC20-790-650-C-4

“Based on inspection, the Vendor failed to equip the restroom used by the children in care with toilet paper, soap and disposable towels or an air dryer within reach of the children. EVIDENCE: The restroom used by the children was not equipped with toilet paper, soap and paper towels.”

8VAC20-790-630-C-2

“Based on inspection, the Vendor failed to ensure electrical outlets have protective covers. EVIDENCE: The Licensing Inspector observed several electrical outlets that were not protected with protective covers. An uncovered electrical outlet was observed beside a infant's crib (child observed sleeping in the crib) that was accessible to the child through the crib slats. A second uncovered electrical outlet was located beside a child sleeping on a cot.”

8VAC20-790-580-A

“Based on record review, the Vendor failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. EVIDENCE: Licensing Inspector reviewed 6 children records. Records for Child #5 and Child #6 did not include documentation of immunizations. The enrollment date for Child #6 is 9/16/2022. Record for Child #5 did not include the 1st day of attendance.”

8VAC20-790-540-B

“Based on record review, the Vendor failed to have the name, home address and telephone number for each parent who has custody, 1st day of attendance, documentation of immunizations on or before the 1st day of attendance and the name address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached. EVIDENCE: The Licensing Inspector reviewed 6 children records. Record for Child #1, Child #2 and Child #5 did not include the address for each parent who has custody. Records for Children #1, #2, #3 #4 and #5 did not include documentation of the 1st day of enrollment. Records for Children #5 and #6 did not have documentation of immunization records received on or before the child's first day of attendance. Records for Children #5 and #6 did not include the name, address and telephone number of at least one person designated by the parent to contact in case of an emergency and the parent cannot be reached.”

22.1-289.031-A-4

“Based on record review & discussion with staff, the Center failed to ensure each staff member 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. EVIDENCE: The Licensing Inspector reviewed 3 staff records. Records for Staff #1 and Staff #2 did not contain documentation of a current staff health report.”

8VAC20-770-40-D-2

“Based on record review, the Center failed to ensure staff, volunteer, or any other person who is expected to be alone with one or more children enrolled in the religious exempt child day center a Sworn Statement or affirmation before employment or commencement of service at the facility and a search of Central Registry within 30 days of employment or commencement of service. EVIDENCE: The Licensing Inspector reviewed 3 staff records. Record for Staff #2 did not contain documentation of a completed Sworn Disclosure or affirmation prior to employment. The hire date was not documented in the record. Records for Staff #1 and Staff #3 did not contain documentation of a completed Central Registry record check before the end of their 30th day of employment. The hire date for Staff #1 and Staff #2 were not identified in their prospective records.”