Mount Calvary Lutheran Church

The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.

“Staff #3, employed for more than 2 years, did not have documentation of requesting a central registry check and sex offender from the state that staff # 3 resided in the preceding five years.”

Rule 22.1-289.031-B-4.

The center is required to have employees undergo a background check every five years.

“The most recent central registry check for staff #5 was overdue by a 5 weeks.”

Rule 22.1-289.035-A.

For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.

“At approximately 8:52 a.m. on 09/30/2024, there were 8 children present in the two-year-old room, no children marked present on the attendance record. On 09/29/2026 no children were marked present on the attendance record. At approximately 9:00 a.m. on 09/30/2024, there were 5 children present in the toddler room, no children marked present on the attendance record. At approximately 9:05 a.m. on 09/30/2024, there were 7 children present in the infant room, no children marked present on the attendance record.”

Rule 8VAC20-790-530-B.

All staff who work directly with children shall have within 90 days of the date of employment.

“Staff # 3 has been employed for over 4 months and did not have First Aid and CPR.”

Rule 8VAC20-790-600-D-2.

Staff and children’s hands shall be washed with soap and running water after toileting.

“Staff and an infant did not wash their hands after a diapering change. The staff used hand sanitizer.”

Rule 8VAC20-790-760-A-1.

The diapering surface shall be cleaned with soap and water and sanitized after each diaper change.

“In the older infant room, the diaper surface was cleaned with soap and water and was not sanitized.”

Rule 8VAC20-790-760-B-8.

An evacuation procedures shall be practiced at least monthly.

“There was no documentation of a drill for February 2025.”

Rule 8VAC20-790-800-A-1.

The following actions or threats thereof are forbidden, roughly handling a child.

“Staff # 1 carried child # 1 (20 months) by the arm up at least three stairs.”

Rule 8VAC20-790-710-1.

Based on record review the facility failed to obtain a sworn statement for one employee prior to employment.

“Evidence: 1. Staff #8 did not have documentation of a sworn statement prior to employment. Date of hire was documented 4.8.2024. 2. Administration confirmed a sworn statement was not obtained.”

Rule 22.1-289.035-B-1.

Based on record review the facility failed to obtain a sworn statement for one employee prior to employment.

“Evidence: 1. Staff #8 did not have documentation of a sworn statement prior to employment. Date of hire was documented 4.8.2024. 2. Administration confirmed a sworn statement was not obtained.”

Rule 22.1-289.035-B-1.

Based on record review the facility failed to obtain a tuberculosis screening for one staff member within 30 days prior to employment.

“Evidence: 1. Staff # 8 did not have documentation of obtaining a tuberculosis screening with 30 days prior to employment. Date of hire was documented 4.8.2024. 2. Administration confirmed there was no documentation for Staff #8 obtaining a tuberculosis screening.”

Rule 8VAC20-790-560-A.

Based on record review the facility failed to have seven staff members obtain an updated tuberculosis screening.

“Evidence: 1. Staff # 1,2,3,4,5,6,and 7 did not have documentation of obtaining an updated tuberculosis screening. 2. Administration confirmed an tuberculosis screening had not been obtained.”

Rule 8VAC20-790-560-B.

Based on record review the facility failed to obtain CPR training within 90 days of hire date.

“Evidence: 1. Staff #9 did not have documentation of obtaining CPR within 90 days of hire. Date of hire was documented 11.20.2023. 2. Staff confirmed no documentation of CPR was on file.”

Rule 8VAC20-790-600-D-1.

Based on record review the facility failed to obtain first aid training within 90 days of hire date.

“Evidence: 1. Staff #9 did not have documentation of obtaining first aid within 90 days of hire. Date of hire was documented 11.20.2023. 2. Staff confirmed no documentation of first aid training was on file.”

Rule 8VAC20-790-600-D-2.

Based on record review the facility failed to have four staff members complete the department’s health and safety update course.

“Evidence: 1. Staff #’s 2, 3, 4 and 5 did not have documentation of completing the departments annual 3- hour health and safety update course. 2. Administration confirmed these staff had not completed the annual 3-hour updated course.”

Rule 8VAC20-790-600-F.

Based on record review, the center failed to obtain documentation of a Virginia Child Protective Service Central Registry check for one staff member.

“Evidence: 1. Fourteen staff records were reviewed. 2. Staff #9 did not have documentation of obtaining a Virginia Child Protective Services Central Registry check within 30 days of hire. 3. Staff #9’s date of hire was documented 11/16/2022. 4. The director confirmed they did not have the results of the Virginia Child Protective Services Central Registry check for Staff # 9.”

Rule 8VAC20-790-550-2-a.

Based on record review, the center failed to obtain an updated criminal history record check for one staff member.

“Evidence: 1. Fourteen staff records were reviewed. 2. Staff #14 had not obtained an updated criminal history record check within 5 years of the prior one dated 02/20/2018. 3. The director confirmed the criminal history record check had not been obtained.”

Rule 8VAC20-790-550-2-f.

Based on observation, the center failed to placed hazardous substances in a locked place that prevents access by children.

“Evidence: 1. One can of Lysol and one container of sanitizing wipes were found on a shelf, unlocked, in the 3-year old classroom. 2. The director confirmed the can of Lysol and sanitizing wipes were not locked and immediately removed them from the classroom.”

Rule 8VAC20-790-640-A.

Based on record review, the center failed to obtain an updated criminal history record check for one staff member.

“Evidence: 1. Fourteen staff records were reviewed. 2. Staff #14 had not obtained an updated criminal history record check within 5 years of the prior one dated 02/20/2018. 3. The director confirmed the criminal history record check had not been obtained.”

Rule 22.1-289.035-A.

Based on record review, the center failed to obtain documentation of a Virginia Child Protective Service Central Registry check for one staff member.

“Evidence: 1. Fourteen staff records were reviewed. 2. Staff #9 did not have documentation of obtaining a Virginia Child Protective Services Central Registry check within 30 days of hire. 3. Staff #9’s date of hire was documented 11/16/2022. 4. The director confirmed they did not have the results of the Virginia Child Protective Services Central Registry check for Staff # 9.”

Rule 8VAC20-770-40-D-2.