Disciples of Christ Fellowship Ministries

TB screening are required at least every two years from the date of the initial screening.

“Staff #2 did not have a current TB screening. It was overdue by 10 months.”

Rule 8VAC20-790-560-B.

Based on inspection, the Center failed to post the fact that it is exempt from licensure in a visible location on the premises.

“EVIDENCE: The religious exempt certificate was not posted in a conspicuous location visible to the parents and the public.”

Rule 22.1-289.031-A. From a complaint.

Based on observation, the center failed to be in compliance with applicable laws and regulations with regard to building codes, and/or the Uniform Statewide Building Code.

“EVIDENCE: 1. There were 10 children in care under the age of 2-1/2 years old. Per the Building Official, the maximum number of children under the age of 2-1/2 years old cannot exceed 5 children. 2. Attendance documents for billed subsidy recorded more than 5 children under the age of 2-1/2 years old were in attendance on the following dates: 2/1/24, 2/2/24, 2/6/24, 2/8/24, 2/9/24, and 2/14/24. Children ranged in age from 3 months to 23 months.”

Rule 22.1-289.031-A-2. From a complaint.

Based on observations, the Center failed to maintain 1 staff member to 5 children from ages 16 months to 24 months.

“EVIDENCE: Upon arrival at 3:00 PM, there were 11 children in care with 2 staff members. The youngest child was 18 months. 3 staff would be required.”

Rule 22.1-289.031-A-3-b. From a complaint.

REPEAT VIOLATION Based on observation, the Center failed to have Fingerprint Background Checks completed for each staff person before date of employment.

“EVIDENCE: Fingerprint Background Checks were unavailable for Staff #2 (unknown date of hire). Staff #2 was observed working with children during the inspection.”

Rule 22.1-289.035-B-2. From a complaint.

REPEAT VIOLATION 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: 1 Staff #1 (date of hire 11/06/2023) did not have a Sworn Disclosure Statement. Staff #1 was observed working with children during the inspection. 2 Staff #2 (date of hire unknown) did not have a Sworn Disclosure Statement. Staff #2 was observed working with children during the inspection. 3 Staff #1 (date of hire 11/06/2023) did not have a Central Registry Check completed within 30 days of hire.”

Rule 8VAC20-770-40-D-2. From a complaint.

Based on inspection, 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 for each group of children.

“EVIDENCE: Written daily attendance was unavailable from January 24 through February 16.”

Rule 8VAC20-790-530-B. From a complaint.

2nd REPEAT VIOLATION Based on record review, the Vendor failed to ensure each staff member is evaluated by a health professional and be issued a statement that the individual is determined to be free of communicable tuberculosis (TB) received at the time of employment and prior to coming into contact with children.

“EVIDENCE: 1. TB skin test/screening was unavailable for Staff #1 (date of hire 11/06/2023). 2. TB skin test/screening was unavailable for Staff #2 (date of hire unavailable). 3. Both staff members were present during the inspection and were observed working with the children in care”

Rule 8VAC20-790-560-A. From a complaint.

Based on observations, the Vendor failed to ensure staff wash their hands with soap and running water before and after changing a diaper.

“EVIDENCE: Licensing Inspector observed staff member changing multiple diapers without washing their hands before and after each diapering.”

Rule 8VAC20-790-760-A-3. From a complaint.

Based on inspection, the Vendor failed to dispose disposable diapers in a leak-proof or plastic lined storage system that is either foot operated or used in such a way that neither the staff member’s hand not the soiled diaper touches an exterior surface of the storage system during disposal.

“EVIDENCE: Licensing Inspector observed 2 uncovered trash cans (infant and toddler areas) used to dispose soiled diapers.”

Rule 8VAC20-790-760-B-6. From a complaint.

Based on observations, the Vendor failed to ensure prepared infant formula is refrigerated, dated and labeled with the child’s name when more than one infant is in care.

“EVIDENCE: Licensing Inspector observed 3 infant bottles containing infant formula/milk sitting on the counter. Bottles were not refrigerated, dated not labeled with names. There were a total of 4 infants present during the inspection.”

Rule 8VAC20-790-820-E. From a complaint.

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.”

Rule 8VAC20-790-530-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.”

Rule 8VAC20-790-540-B.

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.”

Rule 8VAC20-790-550-1.

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.”

Rule 8VAC20-790-560-A.

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.”

Rule 8VAC20-790-600-C.

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.”

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

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.”

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

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.”

Rule 8VAC20-790-600-I.

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.”

Rule 8VAC20-790-630-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.”

Rule 8VAC20-790-640-A.

Based on documentation review, the Vendor failed to have a written emergency preparedness plan.

“EVIDENCE: An emergency preparedness plan was unavailable.”

Rule 8VAC20-790-790-A.

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.”

Rule 8VAC20-790-800-A-2.

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.”

Rule 8VAC20-790-800-A-3.

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.”

Rule 22.1-289.031-A-4.

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.”

Rule 22.1-289.035-A.

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.”

Rule 22.1-289.035-B-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.”

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

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.”

Rule 8VAC20-790-670-C-2. From a complaint.

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.”

Rule 8VAC20-790-670-C-4. From a complaint.

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.

Rule 8VAC20-790-540-B.

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.”

Rule 8VAC20-790-540-B-12.

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.”

Rule 8VAC20-790-580-A.

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.”

Rule 8VAC20-790-630-C-2.

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.”

Rule 8VAC20-790-650-C-4.

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.”

Rule 8VAC20-790-670-E.

Based on inspection, the Vendor failed to have required nonmedical emergency supplies.

“EVIDENCE: A working battery-operated radio was unavailable.”

Rule 8VAC20-790-780-C-2.

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.”

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

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.”

Rule 22.1-289.031-A-4.

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.”

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