Bethel Temple Church, Inc.

22.1-289.035-B-4

“The center is required to obtain background checks from any state in which the individual has resided in the preceding five years. Staff #1, employed for more than 4 months, did not have documentation requesting a criminal history check from one state.”

Rule 22.1-289.035-B-4.

8VAC20-780-160-A

“The center is required to obtain documentation of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children. Staff #3, who is currently working, has a TB screening that was dated 3 days after their first day of employment.”

Rule 8VAC20-780-160-A.

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. The TB screening for staff #5 employed for over 2 years was overdue by 3 months.”

Rule 8VAC20-780-160-C.

Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children.

“1. A bottle of sanitizer was found in Classroom #1 located in an unlocked closet. 2. A bottle of sanitizer was found in Classroom #2 on a shelf in the bathroom. 3. A can of disinfectant spray was found on a counter in Classroom #3.”

Rule 8VAC20-780-280-B.

The diapering surface shall be used only for diapering or cleaning children.

“1. A poster board and a pitcher were located on the diapering surface in Classroom #3. 2. The top for a baby bottle was located on a diapering surface in Classroom #5.”

Rule 8VAC20-780-500-B.

8VAC20-780-70

“Each staff record shall contain the documentation to demonstrate that the individual possesses the education required by the job position. Staff #2, who has been employed for over three months as a lead teacher did not have documented proof of their education.”

Rule 8VAC20-780-70.

8VAC20-780-40-M

“(Repeat violation) The center is required to keep a current list of all known allergies, sensitivities, and dietary restrictions in each room or area where children are present. Two child records showed a dietary restriction that staff were aware of but did not have it noted on a list in those children’s classrooms.”

Rule 8VAC20-780-40-M.

8VAC20-780-560-F

“(Repeat violation) Centers shall follow the most recent requirements of the USDA when they serve meals or snacks. Children were served baked beans with hot dogs, tator tots, applesauce and milk for lunch. There was not a grain served as required by the USDA.”

Rule 8VAC20-780-560-F. From a complaint.

8VAC20-780-500-B

“(Repeat violation) The diapering surface shall be nonabsorbent. The diapering pad in the infant room had two tears causing it be absorbent.”

Rule 8VAC20-780-500-B.

8VAC20-780-550-D

“The center shall conduct an evacuation drill monthly. An evacuation drill was not conducted in June 2024.”

Rule 8VAC20-780-550-D.

Repeat Based on observation and staff interviews, the licensee did not ensure that when centers choose to provide meals or snacks, there shall be a menu listing foods served, to include food substitutions.

“Evidence: The menu posted for April 24, 2024 listed black beans and baked beans were served instead and grapes were served and they were not listed on the menu.”

Rule 8VAC20-780-560-F. From a complaint.

Based on center documentation review and staff interviews, the licensee did not ensure to inform the department’s representative as soon as practicable, but not to exceed two business days, of any injury to a child that occurs while the child is under the supervision of the center and requires outside medical attention.

“Evidence: Child #1 was injured at the center in November 7, 2023 and the injury required outside medical treatment and the department was not notified of the injury.”

Rule 8VAC20-780-80-B-2. From a complaint.

Based on review of five staff records and staff interviews, the licensee did not ensure, all staff obtained a Criminal Records Check prior to the first day of employment

“Evidence: The fingerprint check for Staff #3 was dated 2-7-2023 after employment on 2-1-2023.”

Rule 22.1-289.035-B-2.

Based on record review and staff interviews, the licensee did not ensure each staff member shall submit documentation of a negative tuberculosis screening (TB) prior to employment.

“Evidence: Staff #3?s TB screening was dated 2-16-2023 and first day of employment was 2-1-2023.”

Rule 8VAC20-780-160-A.

Based on observation, staff interviews and record reviews, the licensee did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader.

“Evidence: Staff #2 was observed supervising alone, 7 preschool age children and they do not have documentation of meeting program leader qualifications”

Rule 8VAC20-780-340-D.

Repeat Based on observation and staff interviews, the licensee did not ensure the requirements for diapering were followed.

Rule 8VAC20-780-500-B.

Based on staff interviews and review of documentation, the licensee did not ensure to practice a minimum of twice a year a shelter in place procedure.

“Evidence: Center Director confirmed they did not have documentation of two shelter in place drills in 2023.”

Rule 8VAC20-780-550-E.

Repeat Based on staff interviews and review of documentation, the licensee did not ensure to maintain documentation of monthly emergency evacuation drills.

“Evidence: Staff #2 confirmed they did not have documentation of evacuation drills conducted in November 2023.”

Rule 8VAC20-780-550-G.

Based on observation and staff interviews, the licensee did not ensure to follow the recent, age-appropriate nutritional requirements of the Child and Adult Care Food Program of the United States Department of Agriculture (USDA) when they choose to provide meals and snacks .

“Evidence: Potato chips were served as the designated vegetable for lunch and they do not meet the USDA guidelines.”

Rule 8VAC20-780-560-F.

Repeat Based on a record review and staff interviews, the licensee did not ensure that staff have all required documentation in their record.

“Evidence: The following records were missing information. 1, The records for Staff #1, #2 and #3 did not include the 2 required complete reference checks. 2. The records for Staff #2 and Staff #5, Staff did not include documentation to demonstrate they have the education and experience required by their job position (designated program leads. 3. The records for Staff #2, #3 and #5 did not include a copy of a diploma /transcript.”

Rule 8VAC20-780-70.

Based on record review and staff interviews, the licensee did not ensure all staff shall undergo a background check every five years to include a sworn statement, criminal records check ( CRC ) and search of the central registry check.

“Evidence: Staff #4 did not have an updated CRC as the most recent was dated 9-5-2018.”

Rule 22.1-289.035-A.

Based on record review and staff interviews, the licensee did not ensure each staff member had obtained by the end of the 30th day of hire the results of the Central Registry ( CPS ) finding for the state of Virginia.

“Evidence: Staff # 1?s (hire date 7-24-2023) did not have documentation of CPS results. Staff #4 was observed working on the day of the inspection.”

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

Based on record review and staff interviews, the licensee did not ensure each staff member shall submit documentation of a negative tuberculosis screening (TB) prior to employment and coming in contact with children.

“Evidence: Staff #5?s TB screening was dated 9-8-2023 and was conducted after coming into contact with children on 2-20-2023.”

Rule 8VAC20-780-160-A.

Based on a record review and staff interviews, the licensee did not ensure that staff have completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.

“Evidence: Staff #1?s (hire date was 7-24-2023) record did not include documentation of completing the required Virginia Department of Education-sponsored orientation.”

Rule 8VAC20-780-240-A.

Repeat Based on observation and staff interview, the licensee did not ensure the center shall maintain, in a way that is accessible to all staff who work with children, a current written list of all children’s allergies, sensitivities, and dietary restrictions. This list shall be dated and kept confidential in each room or area where children are present.

“Evidence: Child#6 has dietary restriction (verified by Staff #6), and their name was not listed on the current written list of all children’s allergies, sensitivities, and dietary restrictions.”

Rule 8VAC20-780-40-M.

Based on observation and staff interviews, the licensee did not ensure staff shall wash their hands and children’s hands with soap and running water before and after a diaper change.

“Evidence: Staff #6 was observed changing the diaper for Child #3 and the staff and the child’s hands were not washed with soap and water.”

Rule 8VAC20-780-500-A.

Based on observation and staff interviews, the licensee did not a nonabsorbent surface for diapering or changing shall be used.

“Evidence : In the infant room and in the toddler room the diaper pad was torn and the foam was expowed and the daipe pad si nolonger nonabsorbent.”

Rule 8VAC20-780-500-B.

Based on staff interviews and review of documentation, the licensee did not ensure to maintain documentation of monthly emergency evacuation drills.

“Evidence: Staff #1 confirmed they did not have documentation of evacuation drills conducted in February, March, April, and May 2023.”

Rule 8VAC20-780-550-G.

Based on record review and staff interviews, license did not ensure that children’s records contained all required information.

“Evidence: Child # 1 has a diagnosed food allergy (eggs and shellfish) and the record did not include a written care plan, to include instructions from a physician.”

Rule 8VAC20-780-60-A.

Based on record review and staff interviews, the licensee did not ensure that all required items were in a staff record.

“Evidence: The following information was missing from the staff records. 1.Staff #2, designated as program leader/ lead teacher) did not have documentation they have the experience required by the job position. 2.Staff #3 did not have documentation of 1 of the 2 required references.”

Rule 8VAC20-780-70.

Based on record review and staff interview, the vendor did not ensure staff who work directly with children shall have obtained within 90 days of the date of hire a current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. The training shall include an in- person competency demonstration.

“Evidence: The record for Staff #6 (date of hire 5-12-2022) did not contain current certification in CPR. Staff #7 confirmed that staff #6 was not certified.”

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

22.1-289.035-B-4

Rule 22.1-289.035-B-4.

8VAC20-780-270-A

Rule 8VAC20-780-270-A.

8VAC20-780-280-B

Rule 8VAC20-780-280-B.

8VAC20-780-40-K

“Based on review of center documentation and staff interviews, the licensee did not ensure the center shall develop written procedures for abusive head trauma. Evidence: Staff #7 confirmed there was not a written abusive head trauma policy available for review.”

Rule 8VAC20-780-40-K.

8VAC20-780-40-M

Rule 8VAC20-780-40-M.

Based on observation and staff interviews, the licensee did not ensure handwashing with soap and running water occurred after toileting and any contact with blood feces or urine as required.

“Evidence: Staff # 1 was observed conducting a diaper change for child #1 and child #2 and neither the staff nor the children washed their after the after the diaper change.”

Rule 8VAC20-780-500-A.

Based on observation and staff interviews, the licensee did not ensure the diapering surface was cleaned with soap and at least room temperature water and sanitized after each use.

“Evidence: Staff #1 was observed conducting diaper changes and the diaper pad was not sanitized between diaper changes. Staff #1 used disinfectant wipes between diaper changes. The diaper pad is required to be sprayed with a disinfectant /sanitizing solution and allowed to air dry or wiped down after two minutes. The diaper pad was also not cleaned with a soap and water solution as required.”

Rule 8VAC20-780-500-B.

Based on record review of vendor interviews, the vendor did not ensure, all staff who work directly with children obtain the department’s annual health and safety update course.

“Evidence: The record for staff #3 did not include the annual health and safety update courses. The most recent course for staff #3 was dated June 9, 2020.”

Rule 8VAC20-790-600-F.

Based on observation and staff interviews, the licensee did not ensure that each building that was built before 2015 and that house a child day program that is licensed and serves preschool-age children shall be equipped with at least one carbon monoxide detector.

“Evidence: The center director confirmed they do not have a carbon monoxide detector.”

Rule 22.1-289.058.

Based on a review of 6 staff records and staff interviews, the licensee did not ensure that each staff member had obtained by the end of the 30th day of hire the results of the Central Registry ( CPS ) finding for the state of Virginia.

“Evidence: Staff # 5?s date of hire May 12, 2022 does not have documentation of a CPS check conducted. Staff #5 was observed working on the day of the day of the inspection.”

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

Based on a review of 6 staff records and staff interviews, the licensee did not ensure that each staff member had obtained within 30 days of the first day of employment, training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care.

“Evidence: Staff # 5?s date of hire May 12, 2022 does not have documentation of CPR / first aid training/orientation within the timeframe.”

Rule 8VAC20-780-240-E.

Based on observation and staff interviews, it was determined a center staff did not ensure that behavioral guidance shall be constructive in nature, age and stage appropriate, and shall be intended to redirect children to appropriate behavior.

Rule 8VAC20-780-400-B.

Based on observation and staff interviews, the center failed to ensure that, a staff does not use forbidden action of rough handling.

Rule 8VAC20-780-410-1.

Based on a review of 6 staff records, staff interviews and observation, the licensee did not ensure there was at least one staff in each classroom or area where children are present had obtained a current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children in care Evidence: In the following classrooms there was not a staff member who obtained CPR certification;

“1. In the 2?s room, staff #2 was the only staff observed with 8 children. 2. In the 18 months to 2 year old, staff #4 and staff #5 were they only staff observed with 13 children.”

Rule 8VAC20-780-530-A-1.

Based on record review and staff interviews, the licensee did not ensure there was at least one staff in each classroom or area where children are present had obtained a current certification in first aid.

“Evidence: In the following classrooms there was not a staff member who obtained First Aid certification; 1. In the 2?s room, staff #2 was the only staff observed with 8 children. 2. In the 18 months to 2 year old, staff #4 and staff #5 were they only staff observed with 13 children.”

Rule 8VAC20-780-530-A-2.

Based on a review of 6 children’s records and staff interviews, the licensee did not ensure there was a written care plan for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.

“Evidence: The record for child # 4 has a diagnosed food allergy (milk) and the record did not include a written care plan, to include instructions from a physician.”

Rule 8VAC20-780-60-A.

Based on observation, record review and staff interviews, the licensee did not ensure the staff-to-children ratio 1 staff or every 8 children for the children age 2 was followed.

“Evidence: Between 8:30am and 9:00 am on May 19, 2022 there were 9 children in the two year old classroom, room #106 with 1 staff. Two of the children (child #1 and child #2) on the roll sheet were under 24 months. Child #1 was 23 months old and child #2 was 21 months old”

Rule 8VAC20-780-350-B-3. From a complaint.

Based on staff interviews, record review and observation the licensee did not ensure when a child is assigned to a different age group it is done with a parent’s written permission and a written assessment by the program director and program leader.

“Evidence: Child #1, 23 months old and child #2, 21 months old were assigned to the two year old room. Center director confirmed there was not documentation of a written assessment by the program director and program leader conducted for Child #1 and Child #2.”

Rule 8VAC20-780-350-Q. From a complaint.

Based on staff interviews, record review and observation the licensee did not ensure that when a child may be assigned to a different age group it is done with a parent’s written permission and a written assessment by the program director and program leader.

“Evidence: Child #1, age 21 months was assigned to the two year old room. Center director confirmed there was not documentation of a written assessment by the program director and program leader conducted for Child #1.”

Rule 8VAC20-780-350-Q. From a complaint.

Based on staff interviews and documentation review, the licensee did not ensure that the center shall maintain a written record of children’s serious and minor injuries in which entries are made the day of occurrence and include all required information.

“Evidence: The injury report dated March 30, 2022 for Child #1 did not include how the parent was notified of the injury.”

Rule 8VAC20-780-550-P. From a complaint.

Based on record review and licensee interviews, the licensee did not ensure to a obtain the out of state sex offender check prior to employment. The out of state background checks are required for any person who has lived out side of Virginia within the last five years.

“Evidence: There was not documentation of results of a sex offender check available for review dated prior to employment for Staff #1 who lived in Florida within the last five years, according to center documentation. Staff #1 was date of hire 1-7-21. Center director confirmed information.”

Rule 22.1-289-036-B-4.

Based on record review and licensee interviews, the licensee did not ensure that at least every two years from the date of the first initial tuberculosis screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening.

“Evidence: The record for staff #3 did not include an updated TB screening, as the most recent one available is dated 10-29-2019).”

Rule 8VAC20-780-160-C.

Based on observation and licensee interviews, the licensee did not ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. Unsafe conditions shall include, but not be limited to, splintered, cracked or otherwise deteriorating wood; chipped or peeling paint; visible cracks, bending or warping, rusting or breakage of any equipment; head entrapment hazards; and protruding nails, bolts or other components that could entangle clothing or snag skin.

“Evidence: In room #106, there was a portable sink placed on top of a small wooden pretend stove. The portable skink was designated for staff and children handwashing. The sink moved easily when touched. The wooden stove is approximately 24 inches tall, 19 inches wide and 13 inches deep and the portable sink is approximately 25 inches tall, 15 wide and 7 inches deep. This sink placed on top of the wooden stove presents a safety hazard.”

Rule 8VAC20-780-270-A.

Based on observation and licensee interviews, the licensee did not ensure for diapering there was a sink with running warm water not to exceed 120?F.

“Evidence: In room #106, there were 8 children in diapers and there was a portable sink designated for handwashing. The center staff confirmed the sink broke earlier in the day and there was not another sink available for handwashing.”

Rule 8VAC20-780-500-B.