Ms. Mozhdeh Monjezi

22.1-289.035-B-2

“Providers must obtain a completed national criminal background check prior to the employee’s first day of employment. Caregiver #2, who had been employed for five months, did not have a completed national criminal background check.”

Rule 22.1-289.035-B-2.

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. Caregiver #2, who had been employed for five months, did not have a central registry search requested.”

Rule 22.1-289.035-B-3.

22.1-289.057-A

“The program is required to submit to VDH and implement a plan to test potable water for lead. The program did not have evidence of a testing plan submitted to VDH and the program did not have evidence of the implementation of the required testing plan.”

Rule 22.1-289.057-A.

8VAC20-800-210-A

“Based on review of documentation, the provider failed to obtain 16 clock hours of training annually. Evidence: 1. Staff #1 had 13.5 hours of training on file for the training year of January 24, 2023, to January 23, 2024. No additional documentation of training was provided.”

Rule 8VAC20-800-210-A.

8VAC20-800-830-A

“Based on review of records and interview, the provider failed to practice emergency evacuation procedures monthly. 1. Documentation revealed the last emergency evacuation drill had been practiced in January of 2024. The provider confirmed that the drills had not been practiced monthly.”

Rule 8VAC20-800-830-A.

8VAC20-800-830-B

“Based on review of records and interview, the provider failed to practice shelter-in-place procedures at a minimum of twice per year. Evidence: 1. Documentation revealed shelter-in-place procedures had been practiced on 06/05/2023 and 12/14/2023. The provider confirmed that shelter-in-place procedures had not been practiced twice within the last year.”

Rule 8VAC20-800-830-B.

8VAC20-800-90-C

“Based on review of records, the provider failed to obtain documentation of additional immunizations every six months for children under the age of two. 1. Child #4?s date of birth is 11/14/2022. There was no documentation of immunizations on file for Child #4 between 02/07/2023 and 05/15/2024. 2. Child #5?s date of birth is 03/16/2022. There was no documentation of immunizations on file for Child #5 between the dates of 10/21/2022 and 09/26/2023.”

Rule 8VAC20-800-90-C.

8VAC20-770-60-C-2

“Based on interview and review of records, the provider failed to ensure that central registry background check results were received before the 30th day of employment. Evidence: 1. Staff #3?s start date was 05/01/2023. Staff #3 did not have a central registry background check on file. 2. The provider confirmed that the central registry background check result had not been received.”

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

22.1-289.035-A

“Based on interview and review of records, the provider failed to ensure that criminal history background checks are repeated every five years. Evidence: 1. Staff #1?s last criminal history background check was dated 04/24/2018. 2. Staff #2?s last criminal history background check was dated 04/27/2018. 3. The provider confirmed that the criminal history background checks for Staff #1 and Staff #2 had not been repeated every five years.”

Rule 22.1-289.035-A.

22.1-289.035-B-2

“Based on interview and review of records, the provider failed to ensure that criminal history background check results were received before the first day of employment. Evidence: 1. Staff #3?s start date was 05/01/2023. Staff #3 did not have a criminal history background check on file. 2. The provider confirmed that the criminal history background check had not been conducted.”

Rule 22.1-289.035-B-2.

22.1-289.036-A

“Based on interview and review of records, the provider failed to ensure that criminal history background checks are repeated every five years for household members. Evidence: 1. Household Member #1?s last criminal history background check was dated 04/26/2018. 3. The provider confirmed that the criminal history background check for Household Member #1 had not been repeated every five years.”

Rule 22.1-289.036-A.

8VAC20-770-60-C-2

“Based on interview and review of records, the provider failed to ensure that central registry background check results were received before the 30th day of employment. Evidence: 1. Staff #3?s start date was 05/01/2023. Staff #3 did not have a central registry background check on file. 2. The provider confirmed that the central registry background check result had not been received.”

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

8VAC20-790-170-A

“Based on review of records, the provider failed to obtain from each caregiver at the time of hire documentation of a tuberculosis (TB) screening. Evidence: 1. Staff #3?s start date was 05/01/2023. 2. The TB screening on file for Staff #3 was dated 05/06/2023.”

Rule 8VAC20-790-170-A.

8VAC20-800-350-E

“Based on measurement, the provider failed to ensure that hot water at taps available to children are maintained withing range of 105 degrees and 120 degrees. Evidence: 1. The water in the sink of the children’s restroom was measure at 124.5 degrees.”

Rule 8VAC20-800-350-E.

8VAC20-800-100-A

“Based on review of records and interview, the provider failed to obtain documentation of a physical examine within 30 days after the first day of attendance. Evidence: 1. Child #4?s first day of attendance was 8/16/2022. There was no documentation of a physical examine in the child’s record. 2. The provider confirmed that they did not obtain documentation of a physical examination within 30 days after the first day of attendance.”

Rule 8VAC20-800-100-A.

8VAC20-800-60-B

“Based on review of records, the provider failed to ensure that each child’s record contained results of the health examination for each child. Evidence: 1. Child #1?s record did not contain results from a health examination. 2. The provider confirmed that the child’s record did not contain results from a health examination.”

Rule 8VAC20-800-60-B.

Based on review of two children’s records and verification from the provider, one child’s record did not contain documentation that the child had received a physical examination, which is required within 30 days of the child’s first date of attendance.

“Evidence: 1. The record for Child #2 did not contain a physical examination report. Date of enrollment for Child #2 was 09/15/2021. 2. The provider confirmed that she had not received a physical examination report for Child #2”

Rule 22VAC40-111-100-A.

Based on review of records and verification from the provider, the provider and a household member did not obtained their updated Tuberculosis (TB) test/screening within two years of the most recent one.

“Evidence: 1. The record for the provider and Household Member #1 did not contain a TB screening/test that had been completed within the last two years. The date of the most recent screenings for the provider and Household Member #1 was 07/02/2019. 2. The provider thought they had obtained updated screenings and lost the report, but when she called to obtain copies of the reports, she was told that the last TB that they had received was 07/02/2019.”

Rule 22VAC40-111-180-A.

Based on observation and discussion with the provider, the first-aid kit did not contain all of the required items.

“Evidence: 1. The first-aid kit did not contain a First-Aid Manual. 2. The provider confirmed that she did not have a manual.”

Rule 22VAC40-111-760-A-1.

Based on review of two children’s records and confirmation from the provider, one child’s record did not contain documentation that the child had been adequately immunized which is required before the child’s first date of attendance.

“Evidence: 1. The record for Child #2 did not contain an immunization record. Date of enrollment for Child #2 was 09/15/2021. 2. The provider confirmed that the parent had not given her the child’s immunization record.”

Rule 22VAC40-111-90-A.