Tri-County Community Action Agency, Inc. - Boydton

The center shall provide to the licensing representative an annual fire inspection report from the appropriate fire official.

“The fire inspection report was over 2 months past due.”

Rule 8VAC20-780-260-A.

A tuberculosis (TB) screening is required every two years from the last screening.

“Staff #2 updated screening was overdue by over two weeks.”

Rule 8VAC20-780-160-C.

**Repeat Violation** Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance.

“The physical examination in the record for child #1 was completed over five months after the child’s first date of attendance. The physical examination in the record for child #3 was completed 2 months after the child’s first date of attendance.”

Rule 8VAC20-780-140-A.

**Repeat Violation** Immunization records are required to be signed by a physician, his designee, or an official of the local health department.

“The immunization record for child #3 was not signed.”

Rule 8VAC20-780-150-B.

Staff shall complete a minimum of 16 hours of training annually, appropriate to the age of children in care.

“Staff #1 obtained one of the 16 required hours in 2024.”

Rule 8VAC20-780-245-A.

Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment.

“Staff #1, who has been employed for over 3 years, did not have any completed reference verifications on file.”

Rule 8VAC20-780-70.

The center must obtain the results of a central registry search for an employee, within 30 days of employment.

“The record for staff #3 contained a central registry background check dated 40 days after their date of employment.”

Rule 22.1-289.035-B-3.

Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance.

“There was a physical examination in the record for child #3 dated 45 days after enrollment. There was a physical examination in the record for child #4 dated 56 days after enrollment.”

Rule 8VAC20-780-140-A.

Immunization records are required to be signed by a physician, his designee, or an official of the local health department.

“The immunization records for child #3 and child #4 were not signed.”

Rule 8VAC20-780-150-B.

Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with the children.

“The screening for Staff #1 was completed three weeks after hire and the screening for Staff #3 was completed one day after hire.”

Rule 8VAC20-780-160-A.

The center shall have a qualified program director or qualified back-up program director who shall regularly be on-site at least 50% of the center’s hours of operation.

“Based on interviews with staff, the center does not currently have a program director assigned to the center. Staff reported not having a program director or back-up program director at the center at least 50% of the time.”

Rule 8VAC20-780-200-A.

The center shall maintain documentation of emergency evacuation drills that includes all required components.

“There was no documentation of emergency evacuation drills for the months of September and October 2024.”

Rule 8VAC20-780-550-G.

A menu listing food to be served for meals and snacks during the current one-week period shall: be dated; be posted in a location conspicuous to parents or given to parents; list any substituted food; and be kept on file for one week at the center.

“The center did not have a menu posted for the week of 11/4/24-11/8/24 during the inspection.”

Rule 8VAC20-780-560-F.

Based on a review of documentation and interview, the center did not ensure to obtain annual approval from the health department for meeting the requirements for 1. Water supply; 2. Sewage disposal system; and 3. Food service, if applicable.

“Evidence: 1. The last documentation of a health inspection was 11/30/2022. 2. Administration acknowledged that the inspection was not completed annually as required.”

Rule 8VAC20-780-260-B.

Based on a review of five child records and interview, the center did not ensure that a complete record was kept for one child that contained the required information.

“Evidence: 1. The record of child #4 was missing an emergency contact address. Child records are required to contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. 2. Administration acknowledged that one of the two required emergency contacts did not have an address listed.”

Rule 8VAC20-780-60-A.

Based on observation and interview, the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition.

“Evidence: 1. Rust was observed on the air vents in the two bathrooms used by the children. The vents were located in a low area accessible to the children when using the bathrooms. 2. Torn fabric was observed on the top of a climbing structure on the playground. Several small pieces of the fabric were also observed on the ground. 3. Administration acknowledged that the areas required maintenance.”

Rule 8VAC20-780-270-A.

Based on observation and interview the center did not ensure that a menu listing foods to be served for meals and snacks during the current one-week period was posted in a location conspicuous to parents or given to parents.

“Evidence: 1. On 9/7/2023, a breakfast and lunch menu for the month was observed with the center’s postings. A snack menu was not observed. 2.Administration acknowledged that the snack menu had not been posted or sent to the parents.”

Rule 8VAC20-780-560-F.

Based on a review of three (3) staff records and interview, the center did not ensure that one (1) record contained a central registry finding within 30 days of employment as required.

“Evidence: 1. The record of staff #3 (date of employment: 10/18/2021) contained a central registry finding dated 12/14/2021. 2. Administration acknowledged that they did not have the finding within 30 days.”

Rule 8VAC20-770-60-C-2.

Based on a review of five (5) child records and interview, the center did not ensure that two (2) children had a physical examination by or under the direction of a physician: 1. Before the child’s attendance; or 2. Within 30 days after the first day of attendance.

“Evidence: 1. The record of child #4 (date of attendance: 9/12/2022) and child #5 (date of attendance 9/19/2022) did not contain a physical record. 2. Administration acknowledged that the reports were not obtained.”

Rule 8VAC20-780-140-A.

Based on a review of three (3) staff records and interview, the center did not ensure that one (1) staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.

“Evidence: 1. The record of staff #3 (date of employment 10/18/2021) did not contain documentation of the course completion. 2. Administration acknowledged that it was not completed.”

Rule 8VAC20-780-240-A.

Based on a review of three (3) staff records and interview, the center did not ensure that one (1) staff annually completed a minimum of 16 hours of training appropriate to the age of children in care.

“Evidence: 1. The record of staff #3 (date of employment: 10/18/2021) did not contain 16 hours of annual training. 2. Administration acknowledged that the 16 hours of training was not in the record.”

Rule 8VAC20-780-245-A.

Based on observation and interview, the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition.

“Evidence: 1. A blue climbing structure was observed that had multiple areas of rust. The fabric on top of the climber was ripped. Eight (8) bikes were observed that contained rust. One (1) bike had a torn seat, one (1) bike had a missing handle and one (1) bike had a seat with torn fabric. 2. Administration acknowledged the areas required maintenance.”

Rule 8VAC20-780-270-A.

Based on observation and interview, the first aid kit did not include all required supplies.

“Evidence: 1. The first aid kit contained one (1) triangular bandage. The kits are required to contain more than one. 2. Administration acknowledged that the kit was incomplete.”

Rule 8VAC20-780-540-C.

Based on a review of three (3) staff records and interview, the center did not ensure that one (1) record contained the required information.

“Evidence: 1. The record of staff #3 (date of employment: 10/18/2021) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment as required. 2. Administration acknowledged that the references were not in the record.”

Rule 8VAC20-780-70.

Based on observation and interview, the center did not ensure to equip their building that was built before 2015 and serves preschool children with a carbon monoxide detector.

“Evidence: 1. A carbon monoxide detector was not observed during the virtual inspection. 2. Administration acknowledged that a carbon monoxide detector had not been installed.”

Rule 22.1-289.058.

Based on record review and interview, the center did not ensure to obtain the results of a repeat Central Registry background check every five years as required for one staff.

“Evidence: 1. The record of staff #2 (DOH:08/28/2013) contained documentation of an expired central registry dated 05/17/2016. 2. Administration acknowledged that the background check was expired and they had sent a new request on 09/01/2021.”

Rule 63.2(17)-1720.1-A.