Little Light House Care R&R

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. The record for Staff #3 had documentation of requesting a central registry check from a state two days after beginning employment and it should have been submitted prior to beginning employment. The record for Staff #6, employed for three weeks, did not have documentation of completing a criminal history check, central registry check and sex offender search for one state.

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8VAC20-780-550-P · The center shall keep a written record of children's injuries with required information including staff and parent signatures or two staff signatures. The records for child #3 and child #8 had injury reports that did not have a second signature.

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8VAC20-780-160-C · Each staff member shall obtain updated tuberculosis (TB) screening or testing at least every two years. The record for staff #5 did not have a current TB screening and is overdue by three months.

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22.1-289.057-A · Licensed centers are 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.

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8VAC20-780-160-A · 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 #2 and Staff #7 did not document negative results and the staff members have been working for more than a month.

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8VAC20-780-40-M · Based on observation and interview, facility did not ensure there is a current written list of all children's allergies, sensitivities and dietary restrictions in each room where children are present. The list is to be dated.

Evidence: In the toddler classroom, staff reported child #5 (present in the room) had a food allergy. The allergy was not noted on the allergy list in the room. The allergy list was not dated.

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8VAC20-780-60-A · Repeat Violation

Based on review, facility did not ensure 2 of 5 children's records have documentation of required information. Evidence: The following was found during record review: 1. The record for child #1 did not have start date and the address for the second emergency contact. 2. The record for child #4 (start date 9/5/2023) did not have father's employment information, mother's employment phone number and a second emergency contact.

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8VAC20-780-270-A · Based on observation, facility did not ensure areas and equipment of the center inside and outside are maintained in a clean, safe and operable condition.

Evidence: The following was observed: 1. In the preschool room at approximately 7:15 am, children were observed standing and jumping in front of a flat screen tv while watching a video. The television was within reach of children. The television was not secured and could fall if pressure was applied. 2. In the preschool room, there were areas of peeling paint in two window sills. One window had an area of 3? x 10? section and the other window had an area of 5? x 12?. 3. In the infant 2 room, a cabinet door under the sink was disconnected and propped against the cabinet. 4. In the infant 2 room, a door knob to an adjoining classroom was not secured and was hanging loosely from the door. 5. In the infant 2 room, there was an area 11? x 9? of peeling paint on the wall. 6. In the 2?s room, there were stacked cots that were not stacked properly with some propped upright along the side. The cots could fall if pressure was applied. 7. Program Director observed and confirmed all of the above areas and items.

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8VAC20-790-600-D-1 · Based on review and interview, facility did not ensure staff have current certification in cardiopulmonary resuscitation (CPR) within 90 days of employment.

Evidence: The records for staff #8 (reported start date 3/6/2023) and staff #10 (reported start date 3/2/2023) did not have current CPR. Program Director stated they that are not currently certified and are scheduled to have the training completed.

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8VAC20-770-60-C-2 · Based on review and interview, facility did not ensure 7 of 10 staff records did not have a completed central registry search completed within 30 days of employment.

Evidence: The records for staff #3 (reported start date 4/5/23), staff #4 (reported start date 4/5/23), staff #5 (reported start date 4/10/23), staff #6 (start date 5/8/23), staff #7 (reported start date 5/2/23), staff #8 (reported start date 3/6/23) and staff #10 (reported start date 3/2/23) did not have a completed central registry search. Program Director confirmed final central registry search letters had not been received and did not have documentation of follow up to inquire about the delay.

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8VAC20-780-550-P · Based on review, facility did not ensure 3 of 3 injury reports have documentation of required information.

Evidence: The following was found during review of injury reports: 1. A report completed for child #1 on 3/2/2023 did not document the plan of preventing recurrence. 2. A report completed for child #2 on 3/7/2023 did not document the parent notification (date, time and method), plan of preventing recurrence and a second signature. 3. A report completed for child #3 on 3/2/2023 did not document the date parent notified, method parent notified, plan of preventing recurrence and a second signature.

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