Inspection · 2025-08-12
Licensing Inspector
Arlene Agustin
(804) 629-7519
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 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
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, on-site monitoring inspection was initiated on August 12, 2025 and completed on August 15, 2025. The on-site inspection began at 1pm and ended at 3:30pm. The inspector reviewed compliance in the areas listed above. There were 94 children present and 11 staff. The inspector reviewed 9 children?s records and 5 staff records on-site. This inspection included document review, tour of the facility, interviews, and observations. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.
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. Four of the nine children?s records reviewed did not have additional immunizations updates.
Plan of Correction: Our plan for correction will involve a two-day audit every 30 days. Management team will conduct audits: one party will focus on student files, medical binders, and action plans. Reminders will be sent out to families with 2week window.
Standard 8VAC20-780-160-A
Each staff member shall submit documentation of a negative tuberculosis screening that has been completed within the last 30 calendar days of the date of employment. Staff #1 has a tuberculosis screening that was completed 3 months prior to the date of employment.
Plan of Correction: our plan of correction will involve the management audits: one party will focus on staff files, van updates, and building updates, while the other party will audit student files, medical binders, and action plans.
Standard 8VAC20-780-270-A
Areas and equipment of the center, inside and outside, shall be maintained in a safe and operable condition. The outdoor playground has wooden planks along the bottom of the chain link fence that are rotting which poses a splinter hazard and a large climbing dome that is in the 2-year-old playground however specifically made for children ages 3-10 years old. There is overgrown weeds and grass in the play area.
Plan of Correction: Regarding the physical plants and resilient surfacing, our plan of action to fix this issue is to assign members of management to conduct facility walks twice a week. They will be provided with vendor numbers to obtain estimates for repairs, which will then be submitted for approval with a 72-hour turnaround time. In addition to this, we will be setting up a scheduled plan for beach mulch to come out three times a year, so every four months.
Standard 8VAC20-780-280-B
Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children. A bottle of sanitizer with the warning label, ?Keep out of reach of children,? was unlocked in the children?s bathroom.
Plan of Correction: I will include a weekly reminder in the memo of licensing facts, focusing on two facts per week. We will also conduct a monthly classroom inspection, with follow-up meetings and support.
Standard 8VAC20-780-330-B
Where playground equipment is provided, resilient surfacing shall comply with minimum safety standards and shall be under equipment with moving parts or climbing apparatus to create a fall zone free of hazardous obstacles. The mulch is measuring about an inch in depth on the outdoor playground and under the slides the children were landing in patches of dirt and soil
Plan of Correction: Regarding the physical plants and resilient surfacing, our plan of action to fix this issue is to assign members of management to conduct facility walks twice a week. They will be provided with vendor numbers to obtain estimates for repairs, which will then be submitted for approval with a 72-hour turnaround time. In addition to this, we will be setting up a scheduled plan for beach mulch to come out three times a year, so every four months.
Standard 8VAC20-780-440-B
Cribs shall be identified for use by a specific child. There were no name labels on the cribs in the infant room and there were seven infants in care.
Plan of Correction: Our plan of correction includes adding the labeling of cots and cribs to our new hire training list, cribs being labeled on both sides, and weekly reminder in staff memo with 2 licensing facts per week. We will also conduct a monthly classroom inspection, with follow-up meetings and support.
Standard 8VAC20-780-440-E
There shall be at least 12 inches of space between occupied cots. In the 1 year old room, during nap time, all cots were side by side less than 12 inches of space between them.
Plan of Correction: Our plan of correction includes adding cot spacing and the labeling of cots and cribs to our new hire training list and classroom inspection
Standard 8VAC20-780-580-B
Any vehicle used by the center for the transportation of children shall meet the safety standards set by the Department of Motor Vehicles. The transportation van used that day for a field trip to transport children in care had an expired state inspection dated of June 2025 and expired Virginia State tags dated April 2025.
Plan of Correction: Our plan of correction will The management team will conduct Inspections twice a month: will focus on van updates and building updates, while the other party will audit student files, medical binders, and action plans.
Standard 8VAC20-780-70
Staff records shall have documentation that two or more references as to character and reputation as well as competency were checked before employment. Three of the five staff records reviewed did not have reference checks completed and documented prior to employment.
Plan of Correction: Two parties from the management team will conduct reference checks and sign off them