Hope Lutheran Church

22.1-289.049-A

“Programs shall require that the person enrolling a child in the program present proof of the child's identity and age. The record for child #1 who is enrolled at the center did not have documentation of proof of identity.”

22.1-289.035-B-3

“The center must request a search of the central registry prior to the employee's first day of employment. Staff #4, who had been employed for six years, did not have a central registry search requested. Staff #4 was working alone with children.”

22.1-289.035-B-2

“The center must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #4, who had been employed for six years, did not have a completed national criminal background check.”

22.1-289.035-B-1

“The center is required to obtain a completed sworn statement prior to the employee's first day of employment. Staff #1, staff #2, staff #4, and staff #5 who were all currently working and employed for over two months did not have a completed sworn statement.”

22.1-289.031-B-5

“All areas on the premises accessible to children are free from obvious injury hazards. 1. The Infant 2 Room had phone cord hanging within reach of a crib. 2. The 2 ? - 3 year old room had two metal brackets under a white board sticking out of a wall that was at a child’s head/eye level causing a potential snagging or poking injury. 3. The outdoor plastic water table had a broken section exposed causing a potential snagging or cutting injury.”

22.1-289.035-A

“All employees shall undergo a background check prior to employment and every five years thereafter. Staff #3, who was currently working and employed for over five years had an expired sworn statement in their record.”

22.1-289.031-B-5

“Based on observation it was determined the center did not ensure all areas of the premises accessible to children are free of obvious injury hazards. Evidence: 1. There was a strong unpleasant odor and dark stain under the sink in the infant 2 room. 2. There were three uncapped electrical outlets in the library while occupied by 16-24month old children. 3. There were chemicals in an unlocked cabinet in the 3's room. 4. There were accessible chemicals on top of a cabinet in the 16-24month old's room.”

22.1-289.035-A

“Based on record review and interview it was determined the center did not ensure all employees undergo a background check in accordance with subsection B prior to employment or beginning to serve as a volunteer and every five years thereafter. Evidence: 1. The record for staff #16 did not contain documentation of an updated background check. The last criminal history search was dated conducted 8/13/18. 2. Staff #16 and #20 confirmed this updated background check had not been requested.”

22.1-289.035-B-4

“Based on record review and interview it was determined the center did not obtain a copy of the results of a criminal history record information check, a sex offender registry check, and a search of the child abuse and neglect registry or equivalent registry from any state in which the employee has resided in the preceding five years. Evidence: 1. Staff #10 indicated that the had lived in Kansas within the last five years. There were no out of state background checks for Kansas. 2. Staff #16 and #20 confirmed that these records were not in the record or available during this inspection for staff #10.”

22.1-289.031-A-3-a Complaint related: Yes

“Based on observation, record review, and interviews it was determined that the center has not ensured that the required 1 staff member to every 4 children aged 0 to 16 months is maintained. Evidence: 1. 11 of 12 staff interviewed reported that the ratio for the required age group is not always maintained. 2. Time sheets and sign in logs for 5/8-5/19 show: a. The caterpillar class was over the required 1:4 ratio on 5/15/23 and 5/16/23. b. The firefly class was over the required 1:4 (youngest child 15 months) ratio on 5/9/23, 5/11/23, and 5/15/23. 3. Staff reported: a. The butterfly class was over the required ratio of 1 staff member to every 4 infants at least 9 days in March 2023. b. On 5/25/23 there was one staff member with 7 infants, where 1:4 is required on 5/25/23 in the caterpillar class. c. On 5/25/23 there was one staff member with 6 infants, where 1:4 is required on 5/25/23 in the butterfly class. d. On 5/30/23 there was one staff member with 6 infants, where 1:4 is required on 5/30/23 in the caterpillar class. e. On 3/8/23 staff left the studio twice without communicating with the other staff leaving them out of ratio where 1:4 was required. f. The firefly class (15 months-2 yrs.) is often out of ratio in the mornings. g. Administrative staff reported that 7 staff were out on either the 8th or 9th of May and they were out of ratio due to the staffing shortage. 4. A parent reported witnessing 1 staff with 7 infants that they have observed one staff person in the caterpillar class, at least 2-3 times in the last 30 days. The required infant ratio is 1:4. 5. Teacher and Administrative staff confirmed the center has been out of ratio. 6. Class and Administrative staff members reported that most of the ?out of ratio moments? happen because more children arrive in the morning before additional staff are scheduled to arrive causing them to be out of ratio. 7. Staff and parents have reported the issues with ratio to the Administration, Directors, Pastor, and Elders of the church without any noted changes. 8. Class and Administrative staff cited ?high turnover and lots of call outs? causing the center to be understaffed.”

22.1-289.031-B-2 Complaint related: Yes

“Based on interview it was determined the center has not implemented their procedures for appropriate supervision of children. Evidence: 1. Interviews with multiple staff members confirmed that there have been several occasions within the last 3 months that children have been left alone in building while in care. a. A staff person reported that child #3, 4-year-old, was observed alone in the hallway looking for someone to help her in the restroom. Staff member helped child #3 and took her back to her classroom. Staff did not know how long she was in the hallway alone. Another staff member reported this continues to be an ongoing issue with this child/class. b. Administrative staff acknowledged that although the classroom staff have previously been spoken with regarding bathroom supervision of the children, children, and more specifically child #3, have still been sent to the bathroom without supervision as recently as the last few weeks. c. Staff reported that a 3-year-old child was left alone on 5/17/23 in the area by the kitchen/chapel. d. Two staff members reported that a child was left in the studio around 8 am by their teacher and was taken to their classroom by another staff member. 2. Multiple staff have been observed sleeping in the classroom while they were working. a. On 3/6/23 staff A was observed by two staff other members sleeping in the Butterfly class (infants). b. Administration reported counseling staff A due to sleeping in the classroom. c. Staff reported that staff B was observed sleeping in the caterpillar class on both an unknown date and again in the Butterfly class on 5/19/23.”

22.1-289.031-A-3-d Complaint related: Yes

“Based on observation, record review, and interviews it was determined that the center has not ensured that the required 1 staff member to every 10 children aged 3 to 5 years is maintained. Evidence: 1. 11 of 12 staff interviewed reported that the ratio for the required age group is not always maintained. 2. Staff reported: a. The dragonfly class (3-4 year olds) is usually over the required ratio of 1:10 by 8:30 until 9 am. b. On 5/30/23 there was one staff member with 13 children, where 1:10 is required in the dragonfly class. c. On 5/30/23 at the transition between lunch and nap time one staff member was left alone with 20 children who were not all asleep or laying on their cots in the dragonfly class. 3. On 6/9/23 around 8:30 am this inspector observed: a. The 3?4-year-old class with 1 staff person supervising 12 children where a 1:10 ratio is required. b. The 4?5-year-old class with 1 staff person supervising 12 children where a 1:10 ratio is required. 4. Teacher and Administrative staff confirmed the center has been out of ratio. 5. Class and Administrative staff members reported that most of the ?out of ratio moments? happen because more children arrive in the morning before additional staff are scheduled to arrive causing them to be out of ratio.”

22.1-289.031-B-5 Complaint related: No

“Based on interviews it was determine the center did not ensure all areas of the premises accessible to children are free of obvious injury hazards. Evidence: 1. It was reported that staff have had hot beverages accessible to the children in care in the infant classrooms. a. Staff E was observed by two other staff members holding an infant in one arm and a cup of hot coffee in their other hand. b. Another staff member was observed by staff putting hot tea on a shelf within reach of crawling infants. c. Administrative staff acknowledged being aware of one of the two incidents above and staff ?are not allowed any food or drink in the classrooms?.”

8VAC20-770-40-D-2 Complaint related: No

“Based on record review it was determined the center did not ensure that all employees who are expected to be alone with one or more children enrolled in the religious exempt child day center complete a sworn statement before employment and a search of the central registry is completed within 30 days of employment. Evidence: 1. The record for staff #1 (hired 10/8/21) did not contain documentation of a sworn statement signed prior to employment. The sworn statement in the record was dated 9/13/22. There was no search of the central registry available in the record for staff #1. 2. The record for staff #4 (hired 9/21/21) did not contain documentation of a search of the central registry. 3. The record for staff #5 (hired 1/13/22) did not contain documentation of a sworn statement signed prior to employment. The sworn statement in the record was dated 6/1/22. 4. The record for staff #6 (hired 5/22/22) did not contain a search of the central registry. 5. The record for staff #8 (hired 6/21/2021) did not contain documentation of a search of the central registry.”

22.1-289.035-A Complaint related: No

“Based on record review and interview it was determined the center continued to employ, or permit to serve as a volunteer who will be alone with, in control of, or supervising children any person who (i) has been convicted of any barrier crime as defined in ? 19.2-392.02. Evidence: 1. The record for staff #1 (hired 10/8/21) contained a disqualifying background check dated 10/22/21. 2. Staff #8 reported that the administration was aware of this employee having a disqualifying background check but elected to continue to employ the staff #1.”

22.1-289.031-A-5-c Complaint related: Yes

“Based on interview, video footage viewed, and record review it was determined the center did not ensure that any person 18 years of age or older associated with or employed by any public or private organization responsible for the care of children; who, in their professional or official capacity, have reason to suspect that a child is an abused or neglected child, reported the matter immediately to the local department of the county or city wherein the child resides or wherein the abuse or neglect is believed to have occurred or to the Department's toll-free child abuse and neglect hotline. Evidence: 1. There was no report made by the center about child #1 being left unattended on the playground on 9/6/22. 2. Interviews confirm that no report was made regarding the above incident.”

22.1-289.035-B-2 Complaint related: No

“Based on record review it was determined the center did not ensure that all staff submit to fingerprinting as required. Evidence: 1. The record for staff #1 (hired 10/8/21)did not contain documentation of fingerprinting prior to employment. The fingerprinting results were dated 10/22/21. 2. The record for staff #4 (hired 9/21/21) did not contain documentation of fingerprinting prior to employment. 3. The record for staff #5 (hired 1/13/22) did not contain documentation of fingerprinting prior to employment. The fingerprinting results were dated 1/26/22. 4. The record for staff #6 (hired 5/22/22)did not contain documentation of fingerprinting prior to employment. The fingerprinting results were dated 9/12/22. 5. The record for staff #7 (hired 3/8/21)did not contain documentation of fingerprinting prior to employment. The fingerprinting results were dated 9/8/21. 6. The record for staff #8 (hired 6/21/21) did not contain documentation of fingerprinting prior to employment.”

22.1-289.031-B-2 Complaint related: No

“Based on interview, video footage viewed, and record review it was determined the center did not ensure appropriate supervision was given to all children in care to ensure their safety. Evidence: 1. Video footage from 9/6/22 showed the two staff members(staff #1 and staff #3) and children from the two year old class and the two staff members(staff #2 and staff #4) and children from the three year old class leaving the playground at 12:07 pm and entering the center at 12:09pm. Child #1(DOB 9/4/20) from the two year old class is seen alone on the playground from 12:09 pm until 12:22 pm when a staff member(staff #6) returning from break retrieved child #1 from the playground and brought them back into the center at 12:24 pm. 2. Staff interviews confirmed child #1 was left unattended on the playground. 3. Video footage dated 9/6/22 at 12:07 pm showed child #4 on the side of the shed which is located partially on the paved parking lot. A van was observed driving directly in front of the shed with the child standing at the corner of the shed closest to the passing van. Staff members seen in this footage would not be able to see the child and van.”

8VAC20-770-40-D-2 Complaint related: No

“Based on record review it was determined the center did not ensure that all employees who are expected to be alone with one or more children enrolled in the religious exempt child day center complete a sworn statement before employment and a search of the central registry is completed within 30 days of employment. Evidence: 1. The record for staff #1 (hired 10/8/21) did not contain documentation of a sworn statement signed prior to employment. The sworn statement in the record was dated 9/13/22. There was no search of the central registry available in the record for staff #1. 2. The record for staff #4 (hired 9/21/21) did not contain documentation of a search of the central registry. 3. The record for staff #5 (hired 1/13/22) did not contain documentation of a sworn statement signed prior to employment. The sworn statement in the record was dated 6/1/22. 4. The record for staff #6 (hired 5/22/22) did not contain a search of the central registry. 5. The record for staff #8 (hired 6/21/2021) did not contain documentation of a search of the central registry.”

22.1-289.035-A Complaint related: No

“Based on record review and interview it was determined the center continued to employ, or permit to serve as a volunteer who will be alone with, in control of, or supervising children any person who (i) has been convicted of any barrier crime as defined in ? 19.2-392.02. Evidence: 1. The record for staff #1 (hired 10/8/21) contained a disqualifying background check dated 10/22/21. 2. Staff #8 reported that the administration was aware of this employee having a disqualifying background check but elected to continue to employ the staff #1.”

22.1-289.031-A-5-c Complaint related: Yes

“Based on interview, video footage viewed, and record review it was determined the center did not ensure that any person 18 years of age or older associated with or employed by any public or private organization responsible for the care of children; who, in their professional or official capacity, have reason to suspect that a child is an abused or neglected child, reported the matter immediately to the local department of the county or city wherein the child resides or wherein the abuse or neglect is believed to have occurred or to the Department's toll-free child abuse and neglect hotline. Evidence: 1. There was no report made by the center about child #1 being left unattended on the playground on 9/6/22. 2. Interviews confirm that no report was made regarding the above incident.”

22.1-289.035-B-2 Complaint related: No

“Based on record review it was determined the center did not ensure that all staff submit to fingerprinting as required. Evidence: 1. The record for staff #1 (hired 10/8/21)did not contain documentation of fingerprinting prior to employment. The fingerprinting results were dated 10/22/21. 2. The record for staff #4 (hired 9/21/21) did not contain documentation of fingerprinting prior to employment. 3. The record for staff #5 (hired 1/13/22) did not contain documentation of fingerprinting prior to employment. The fingerprinting results were dated 1/26/22. 4. The record for staff #6 (hired 5/22/22)did not contain documentation of fingerprinting prior to employment. The fingerprinting results were dated 9/12/22. 5. The record for staff #7 (hired 3/8/21)did not contain documentation of fingerprinting prior to employment. The fingerprinting results were dated 9/8/21. 6. The record for staff #8 (hired 6/21/21) did not contain documentation of fingerprinting prior to employment.”

22.1-289.031-B-2 Complaint related: No

“Based on interview, video footage viewed, and record review it was determined the center did not ensure appropriate supervision was given to all children in care to ensure their safety. Evidence: 1. Video footage from 9/6/22 showed the two staff members(staff #1 and staff #3) and children from the two year old class and the two staff members(staff #2 and staff #4) and children from the three year old class leaving the playground at 12:07 pm and entering the center at 12:09pm. Child #1(DOB 9/4/20) from the two year old class is seen alone on the playground from 12:09 pm until 12:22 pm when a staff member(staff #6) returning from break retrieved child #1 from the playground and brought them back into the center at 12:24 pm. 2. Staff interviews confirmed child #1 was left unattended on the playground. 3. Video footage dated 9/6/22 at 12:07 pm showed child #4 on the side of the shed which is located partially on the paved parking lot. A van was observed driving directly in front of the shed with the child standing at the corner of the shed closest to the passing van. Staff members seen in this footage would not be able to see the child and van.”