Inspection · 2025-04-02
Date
2025-04-02
Complaint Related
Yes
Licensing Inspector
Lauren Captain
(571) 835-0599
(571) 835-0599
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
No
Areas Reviewed
8VAC20-780 Administration.
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-820 THE LICENSE.
8VAC20-770 Background Checks
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect
20 Access to minor?s records
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.
Inspector Notes
An unannounced inspection was initiated on March 6, 2025 in response to a complaint received by the licensing office on 03/03/25 relating to allegations of staffing and supervision and daily activities. The inspector reviewed six children's records and six staff records on-site. This inspection included document review, tour of the facility, interviews and observations. The preponderance of evidence gathered during the investigation does not support the allegations; therefore the complaint is determined to be not valid. Though not a part of the original compliant, violations that were not reported were found related to administration, and staff-to-children ratio requirements and are documented on the violation notice issued to the program.
Violations
6Standard 8VAC20-780-130-A
The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Child #4, who had been attending for over six weeks, did not have documentation of an immunization record on file.
Plan of Correction: Management staff will undergo immediate retraining of enrollment requirements including immunizations. To ensure ongoing compliance and to prevent future issues with missing records the following oversight measure will be implemented. Monthly file audits, a log will be maintained to track all files. No later than 4/11/2025.
Standard 8VAC20-780-130-E
The Center shall obtain documentation of additional immunizations once every six months for children under the age of two years. Child #3, who has been attending four months, and is under the age of two years of age, does not have additional immunizations on file. The last documentation of immunization is dated 7/29/24.
Plan of Correction: Management staff will undergo immediate retraining of enrollment requirements including immunizations. To ensure ongoing compliance and to prevent future issues with missing records the following oversight measure will be implemented. Monthly file audits, a log will be maintained to track all files. No later than 4/11/2025.
Standard 8VAC20-780-140-A
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 no physical examination in the record for child #4, who had been enrolled for three months.
Plan of Correction: Management staff will undergo immediate retraining of enrollment requirements including physical examinations. To ensure ongoing compliance and to prevent future issues with missing records the following oversight measure will be implemented. Monthly file audits, a log will be maintained to track all files. No later than 4/11/2025.
Standard 8VAC20-780-350-B-1
The staff-to-children ratios as specified are required whenever children are in care.
The ratio for Birth up to 16 months 1 staff to 4 children; 16 months up to 24 months is one staff to 5 children; 2 year olds is one staff to 8 children; 3 year olds up to to school age eligible is one staff to ten children; and school age eligible up to 9 years is one staff to 18 children.
On 2/24/25 Class # 6 was over ratio due to various ages in attendance, to include children under the age of one year old, requiring the ratio be one-to-four. At 7:00am, Class # 6 had one staff to five children and one child was under 12 months of age. At 7:30am, Class #6 had 14 children with one teacher ranging in ages from 11 months through 11 years of age (required ratio one-to-four). Class #2 (ages 21 months - 24 months) had five children with one teacher (required ratio is one-to-four).
On 02/25/25 Class # 6 was over ratio due to various ages in attendance, to include children under the age of one year old, which requiring the ratio be one-to-four. At 6:33AM, Class #6 had one staff with 5 children and one child was 10 months of age. At 7:00AM , Class #6 had 11 children ranging from 10 months to 9 years with two staff which requires a ratio of one-to-four.
On 02/26/25 Class #6 is over-ratio from 6:47AM to 7:20AM, due to various ages in attendance, to include children under one year of age. At 6:47AM, staff #6 has 5 children that includes a 10 month old, requiring the ratio to be one-to-four. At 7:00AM to 7:20AM, Class #6 had nine children with one teacher ranging in ages from 10 months through 9 years of age (required ratio is one-to-four).
On 03/06/25 Class #6 is over ratio at 7:30AM due to various ages in attendance, to include children under the age of one year old. Staff #6 has 12 children.
3/13/25 Class #6 is over-ratio at 7:00 - 7:20AM due to various ages in attendance, to include children under the age of one year old, requiring the ratio be one-to-four. At 7:00AM, Staff #6 has five children, ages 11 months - 6 years of age. At 7:30 AM, Staff #6 has six children, ages five months to 11 years. At 10:00 AM, Staff #6 has nine children, ages five months to six years.
The ratio for Birth up to 16 months 1 staff to 4 children; 16 months up to 24 months is one staff to 5 children; 2 year olds is one staff to 8 children; 3 year olds up to to school age eligible is one staff to ten children; and school age eligible up to 9 years is one staff to 18 children.
On 2/24/25 Class # 6 was over ratio due to various ages in attendance, to include children under the age of one year old, requiring the ratio be one-to-four. At 7:00am, Class # 6 had one staff to five children and one child was under 12 months of age. At 7:30am, Class #6 had 14 children with one teacher ranging in ages from 11 months through 11 years of age (required ratio one-to-four). Class #2 (ages 21 months - 24 months) had five children with one teacher (required ratio is one-to-four).
On 02/25/25 Class # 6 was over ratio due to various ages in attendance, to include children under the age of one year old, which requiring the ratio be one-to-four. At 6:33AM, Class #6 had one staff with 5 children and one child was 10 months of age. At 7:00AM , Class #6 had 11 children ranging from 10 months to 9 years with two staff which requires a ratio of one-to-four.
On 02/26/25 Class #6 is over-ratio from 6:47AM to 7:20AM, due to various ages in attendance, to include children under one year of age. At 6:47AM, staff #6 has 5 children that includes a 10 month old, requiring the ratio to be one-to-four. At 7:00AM to 7:20AM, Class #6 had nine children with one teacher ranging in ages from 10 months through 9 years of age (required ratio is one-to-four).
On 03/06/25 Class #6 is over ratio at 7:30AM due to various ages in attendance, to include children under the age of one year old. Staff #6 has 12 children.
3/13/25 Class #6 is over-ratio at 7:00 - 7:20AM due to various ages in attendance, to include children under the age of one year old, requiring the ratio be one-to-four. At 7:00AM, Staff #6 has five children, ages 11 months - 6 years of age. At 7:30 AM, Staff #6 has six children, ages five months to 11 years. At 10:00 AM, Staff #6 has nine children, ages five months to six years.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-40-E
The operation responsibilities of the licensee shall ensure that the center's activities, services and facilities are maintained in compliance with the center's own policies and procedures that are required by these standards. The Face-to-Name Transition Sheet did not have complete documentation of the arrival and/or departure of children and staff in the classrooms. On 2/24/25, Class #2 did not document the departure of five children, Class #4 and #5 did not document the departure of seven children respectively.
On 2/25/25, Class #1 did not document the departure of three children, Class #2 did not document the departure of 3 children, Class # did not document the departure of two children, and Class #6 did not document the departure of two children.
On 2/26/25, Class #2 did not document the departure of 3 children, Class #3 did not document the arrival of 12 children and did not document the departure of three children, Class #5 did not document the departure of two children, and Class #6 did not document the departure of four children.
The Staff did not document their arrival or departure time on the Face-To-Name Transition Sheet. Staff #2 did not document time out in Class #1 on 2/24/25 and 2/25/25. Staff #4 did not document time out in Class #2 on 2/24/25, 2/25/25, and 2/26/25. Staff # 5 did not document time out in Class #4 on 2/24/25 and 2/25/25, and Staff #8 did not document time out in Class #4 on 2/24/25, 2/26/25, Staff #7 did not document time out on 2/24/25 and 2/25/25 in class #6 and on 2/26/25 in Class #5.
On 2/25/25, Class #1 did not document the departure of three children, Class #2 did not document the departure of 3 children, Class # did not document the departure of two children, and Class #6 did not document the departure of two children.
On 2/26/25, Class #2 did not document the departure of 3 children, Class #3 did not document the arrival of 12 children and did not document the departure of three children, Class #5 did not document the departure of two children, and Class #6 did not document the departure of four children.
The Staff did not document their arrival or departure time on the Face-To-Name Transition Sheet. Staff #2 did not document time out in Class #1 on 2/24/25 and 2/25/25. Staff #4 did not document time out in Class #2 on 2/24/25, 2/25/25, and 2/26/25. Staff # 5 did not document time out in Class #4 on 2/24/25 and 2/25/25, and Staff #8 did not document time out in Class #4 on 2/24/25, 2/26/25, Staff #7 did not document time out on 2/24/25 and 2/25/25 in class #6 and on 2/26/25 in Class #5.
Plan of Correction: All staff will undergo immediate retraining on the proper face-to-name procedures. This includes reviewing when checks must take place, arrival of staff and child, transitions, outdoor play, napping and departure. The following oversight measures will be added. Director or person of management will conduct daily walkthroughs.
Standard 8VAC20-780-40-G
The center shall meet the proof of child identity and age requirements as stated in the Code of Virginia within seven business days of the initial attendance. Child #4 has been enrolled for over five months, and there is no documentation on file showing the child's proof of identity and age requirements.
Plan of Correction: Management staff will undergo immediate retraining of enrollment requirements including identity and age requirements. To ensure ongoing compliance and to prevent future issues with missing records the following oversight measure will be implemented. Monthly file audits, a log will be maintained to track all files. No later than 4/11/2025.