Inspection · 2025-04-01
Date
2025-04-01
Complaint Related
No
Licensing Inspector
Kristy Atanackovic
(804) 629-5032
(804) 629-5032
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
63.2 Child Abuse & Neglect
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
Inspector Notes
An unannounced monitoring inspection was initiated on 4/1/2025 and completed on 5/1/2025 in response to a self-report received by the licensing office on 3/26/2025 relating to behavior guidance and forbidden action. The inspector reviewed 1 child?s record on-site and 6 staff records off-site. This inspection included document review and interviews.
Though not a part of the original self-report, violations that were not reported were found related to reporting and operational responsibilities and are documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the violation will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 5/7/2025. A POC submitted after this date will not appear on the public website.
Violations
4Standard 8VAC20-780-340-A
When staff are supervising children, they shall always ensure their care, protection, and guidance.
On January 17, 2024, Staff #2 stated that Child #1 requested an ice pack and reported that their back hurt and they were feeling pain on the right side because Staff #1 pushed them. Staff #2 stated that they gave the child an ice pack and had the child rest for approximately 5-10 minutes. The incident that Child #1 reported to Staff #2, along with the need for an ice pack that day, was not reported.
On January 18, 2024, the parents of Child #1 reported to the center that Child #1 told them of two incidents that happened on January 17, 2024, where Staff #1 put their hands on them in an inappropriate way. Child #1 reported they were slugged in the arm in the first occurrence and then punched in the arm on the second occurrence. On January 23, 2024, Staff #5 documented the steps taken and next steps regarding the reported incidents on January 17, 2024, to the parents of Child #1, stating that Staff #1 ?will not return to Churchill Road to provide coverage in the absence of staff.? Staff #1 was later sent to Churchill Road SACC on Monday, March 24, 2025, while Child #1 was in attendance that day.
On January 17, 2024, Staff #2 stated that Child #1 requested an ice pack and reported that their back hurt and they were feeling pain on the right side because Staff #1 pushed them. Staff #2 stated that they gave the child an ice pack and had the child rest for approximately 5-10 minutes. The incident that Child #1 reported to Staff #2, along with the need for an ice pack that day, was not reported.
On January 18, 2024, the parents of Child #1 reported to the center that Child #1 told them of two incidents that happened on January 17, 2024, where Staff #1 put their hands on them in an inappropriate way. Child #1 reported they were slugged in the arm in the first occurrence and then punched in the arm on the second occurrence. On January 23, 2024, Staff #5 documented the steps taken and next steps regarding the reported incidents on January 17, 2024, to the parents of Child #1, stating that Staff #1 ?will not return to Churchill Road to provide coverage in the absence of staff.? Staff #1 was later sent to Churchill Road SACC on Monday, March 24, 2025, while Child #1 was in attendance that day.
Plan of Correction: Staff will ensure the care, protection and guidance of all children at all times. Staff will ensure any incidents and incident responses are reported to the direct supervisor, and follow the reporting procedures of the agency for appropriate awareness and to support implementation of the response. Date of Correction: 5/8/2025
Standard 8VAC20-780-550-O
The center shall notify the parent by the end of the day of any known minor injuries.
On January 17, 2024, Staff #2 stated that Child #1 requested an ice pack and reported that their back hurt and they were feeling pain on the right side because Staff #1 pushed them. Staff #2 stated that they gave the child an ice pack and had the child rest for approximately 5-10 minutes. The parents of Child #1 were not notified by the end of the day and were not informed that an ice pack was given to Child #1 until five days later.
On January 17, 2024, Staff #2 stated that Child #1 requested an ice pack and reported that their back hurt and they were feeling pain on the right side because Staff #1 pushed them. Staff #2 stated that they gave the child an ice pack and had the child rest for approximately 5-10 minutes. The parents of Child #1 were not notified by the end of the day and were not informed that an ice pack was given to Child #1 until five days later.
Plan of Correction: Staff will consistently follow procedures for injury notification, including notifying the parent by the end of the day of any minor injury. Date of Correction: 5/8/2025
The regional manager will review the injury log during site visits. Date of Correction: Ongoing
The regional manager will review the injury log during site visits. Date of Correction: Ongoing
Standard 8VAC20-780-550-P
The center shall maintain a written record of children's serious and minor injuries, in which entries are made the day of occurrence. The record shall include staff and parent signatures or two staff signatures.
The injury report for Child #1 was completed on January 23, 2024, not on the day of the occurrence, which was January 17, 2024. The injury report is also missing a staff and parent signature, or two staff signatures.
The injury report for Child #1 was completed on January 23, 2024, not on the day of the occurrence, which was January 17, 2024. The injury report is also missing a staff and parent signature, or two staff signatures.
Plan of Correction: Staff will consistently follow procedures for documentation of injuries, to include documenting the injury on the day of occurrence and ensuring two signatures are documented on the form. Date of Correction: 5/8/2025
The regional manager will review the injury log during site visits. Date of Correction: Ongoing
The regional manager will review the injury log during site visits. Date of Correction: Ongoing
Standard 8VAC20-780-80-B
Any suspected incident of child abuse shall be reported to Child Protective Services (CPS) immediately.
On January 17, 2024, Staff #2 stated that Child #1 (age 10 years old) requested an ice pack and reported that their back hurt and they were feeling pain on the right side because Staff #1 pushed them.
On January 18, 2024, the parents of Child #1 reported to the center that Child #1 told them of two incidents that occurred on January 17, 2024, where Staff #1 put their hands on them in an inappropriate way. Child #1 reported they were slugged in the arm in the first occurrence and then punched in the arm on the second occurrence.
The center did not report the suspected incident of child abuse to Child Protective Services (CPS) immediately after being notified of the two incidents. The center reported that they notified CPS 14 months later.
On January 17, 2024, Staff #2 stated that Child #1 (age 10 years old) requested an ice pack and reported that their back hurt and they were feeling pain on the right side because Staff #1 pushed them.
On January 18, 2024, the parents of Child #1 reported to the center that Child #1 told them of two incidents that occurred on January 17, 2024, where Staff #1 put their hands on them in an inappropriate way. Child #1 reported they were slugged in the arm in the first occurrence and then punched in the arm on the second occurrence.
The center did not report the suspected incident of child abuse to Child Protective Services (CPS) immediately after being notified of the two incidents. The center reported that they notified CPS 14 months later.
Plan of Correction: Staff will immediately report to CPS any incident of suspected, reported or alleged abuse. Date of Correction: 5/8/2025
The regional manager will review CPS mandated reporter procedures with center staff. Date of Correction: 5/16/2025
Regional managers programwide will review mandated reporter requirements with staff. Date of Correction: 5/31/2025
The regional manager will review CPS mandated reporter procedures with center staff. Date of Correction: 5/16/2025
Regional managers programwide will review mandated reporter requirements with staff. Date of Correction: 5/31/2025