Inspection · 2025-03-27
Date
2025-03-27
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 Staffing Qualifications and Training
8VAC20-780 Staffing and Supervision
Inspector Notes
An unannounced inspection was initiated on March 27, 2025 and completed on April 10, 2025 in response to a complaint received by the licensing office on March 26, 2025 relating to allegations of staffing and supervision. The inspector reviewed three children's records and five staff records on-site. This inspection included document review, interviews, and observations.
The preponderance of evidence gathered during the investigation supports the allegation; therefore, the complaint is determined to be valid. Information gathered during the investigation determined non-compliance with applicable standards or law and the violations are documented on the violation notice issued to the program.
Violations
5Standard 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 #3, who had been attending for five months, did not have documentation of an immunization record on file.
Repeat Violation
Repeat Violation
Plan of Correction: -Comprehensive review of all student files by director will take place, with immediate concerns being addressed immediately for attendance to continue. Date to be corrected by 04/18/25.
-Policy enforced by director and assistant director that no new enrollment can attend until all required documentation is in hand. Date to be corrected: 04/11/2025.
-Director will implement online tracking procedures that notifies of updates needed (i.e. immunizations, physicals). Date to be corrected by 04/18/2025.
-Policy enforced by director and assistant director that no new enrollment can attend until all required documentation is in hand. Date to be corrected: 04/11/2025.
-Director will implement online tracking procedures that notifies of updates needed (i.e. immunizations, physicals). Date to be corrected by 04/18/2025.
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. The records for Child #1 did not have documentation of additional immunizations every six months. The last documentation of additional immunizations was over eight months ago. The child was in care at the time of the inspection and has been enrolled for over a year.
Repeat Violation
Repeat Violation
Plan of Correction: -Comprehensive review of all student files by director will take place, with immediate concerns being addressed immediately for attendance to continue. Date to be corrected by 04/18/25.
-Policy enforced by director and assistant director that no new enrollment can attend until all required documentation is in hand. Date to be corrected: 04/11/2025.
- Director will implement online tracking procedure that notifies of updates needed (i.e. immunizations, physicals). Date to be corrected by 04/18/2025.
-Policy enforced by director and assistant director that no new enrollment can attend until all required documentation is in hand. Date to be corrected: 04/11/2025.
- Director will implement online tracking procedure that notifies of updates needed (i.e. immunizations, physicals). Date to be corrected by 04/18/2025.
Standard 8VAC20-780-140-A
Physical examination 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 #3, who had been enrolled for five months.
Repeat Violation
Repeat Violation
Plan of Correction: -Comprehensive review of all student files by director will take place, with immediate concerns being addressed immediately for attendance to continue. Date to be corrected by 04/18/25.
-Policy enforced by director and assistant director that no new enrollment can attend until all required documentation is in hand. Date to be corrected: 04/11/2025.
-Director will implement online tracking procedures that notifies of updates needed (i.e. immunizations, physicals). Date to be corrected by 04/18/2025.
-Policy enforced by director and assistant director that no new enrollment can attend until all required documentation is in hand. Date to be corrected: 04/11/2025.
-Director will implement online tracking procedures that notifies of updates needed (i.e. immunizations, physicals). Date to be corrected by 04/18/2025.
Standard 8VAC20-780-350-A
The required ratio for children ages 16 to 24 month is one staff per five children. On 3/26/25, Staff #3 supervised eight children (youngest 18 months) from approximately 9:47am - 5:55PM. Staff #2 supervised eight children (youngest 18 months) from approximately 11:57am - 1:11pm.
Staff #3 and Staff #5 were observed supervising thirteen children (youngest child 17 months old) from approximately 12:02pm - 12:30pm.
Repeat Violation
Staff #3 and Staff #5 were observed supervising thirteen children (youngest child 17 months old) from approximately 12:02pm - 12:30pm.
Repeat Violation
Plan of Correction: -Staff will be retrained on ratio requirements, with ratio requirements posted in classrooms. Date to be corrected by 04/25/2025.
-Director and assistant director practice will include daily room spot checks and monitoring of attendance to ensure ratios are met at all times. Date to be corrected by 04/11/2025.
-Director and assistant director practice will include daily room spot checks and monitoring of attendance to ensure ratios are met at all times. Date to be corrected by 04/11/2025.
Standard 8VAC20-780-40-E
The operational responsibilities of the licensee shall include ensuring 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 and the F2N Count. On 3/26/25, Class #1 did not document 13/20 children departing the class and two children's departure time did not match the time of arrival into Class #2. Staff #1 and Staff #2, did not document time of departure from their classrooms. The F2N Count did not have complete documentation for all the classrooms throughout the day.
On 3/27/25, Staff #3, #5, and #6 did not document departure time from their classroom. The F2N Count did not have complete documentation for all the classrooms throughout the day.
Repeat Violation
On 3/27/25, Staff #3, #5, and #6 did not document departure time from their classroom. The F2N Count did not have complete documentation for all the classrooms throughout the day.
Repeat Violation
Plan of Correction: -Staff will have comprehensive retraining on Face-to-Name Procedures on 4/30/25
-Director and assistant director will implement daily spot checks of Name-to-Face sheets in each classroom, noting any concerns with teachers immediately, corrected by 4/14/25.
-Director and assistant director will implement daily spot checks of Name-to-Face sheets in each classroom, noting any concerns with teachers immediately, corrected by 4/14/25.