Inspection · 2025-12-19
Date
2025-12-19
Complaint Related
No
Licensing Inspector
Dominick Fields
(540) 359-5244
(540) 359-5244
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
Violations
8Standard 22.1-289.035-B-1
A sworn statement or affirmation disclosing whether employees have been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth.
Staff #2 employed for one month did not have evidence of a completed sworn disclosure.
Staff #2 employed for one month did not have evidence of a completed sworn disclosure.
Plan of Correction: The sworn statement will be in the file immediately. Employee cannot return until completed.
?Adhere to agency's pre-employment checklist and hiring procedures to ensure completion of the sworn statement prior to start date for all new employees effective immediately (as described above). Ongoing.
?File audit completed as part of orientation and onboarding by Director and/or Assistant Director to verify inclusion of sworn statements at hire for all personnel. Ongoing.
?Adhere to agency's pre-employment checklist and hiring procedures to ensure completion of the sworn statement prior to start date for all new employees effective immediately (as described above). Ongoing.
?File audit completed as part of orientation and onboarding by Director and/or Assistant Director to verify inclusion of sworn statements at hire for all personnel. Ongoing.
Standard 22.1-289.035-B-4
REPEAT VIOLATION
A search of the sex offender registry and child abuse and neglect registry from any state in which the individual has resided in the preceding five years must be conducted prior to employment.
Staff #2 resided in one state outside of Virginia in the preceding five years. The center did not conduct a search of the sex offender registry and child abuse and neglect registry for that state. Staff #2 has been employed one month.
A search of the sex offender registry and child abuse and neglect registry from any state in which the individual has resided in the preceding five years must be conducted prior to employment.
Staff #2 resided in one state outside of Virginia in the preceding five years. The center did not conduct a search of the sex offender registry and child abuse and neglect registry for that state. Staff #2 has been employed one month.
Plan of Correction: ?Completed: Reviewed all staff background check records to verify required registry searches have been completed.
?Complete missing registry checks for any affected staff and place documentation in personnel files by 1/15//2025. Employee cannot return until completed. Employee in question transferred into the center from another position and had met all the required background checks for that role. Updating procedures for all employees to match the standard required.
?Complete missing registry checks for any affected staff and place documentation in personnel files by 1/15//2025. Employee cannot return until completed. Employee in question transferred into the center from another position and had met all the required background checks for that role. Updating procedures for all employees to match the standard required.
Standard 8VAC20-780-160-C
REPEAT VIOLATION
A tuberculosis (TB) screening is required every two years from the last screening.
Staff #1 updated screening was due eight days ago. The updated screenings have not yet been completed.
A tuberculosis (TB) screening is required every two years from the last screening.
Staff #1 updated screening was due eight days ago. The updated screenings have not yet been completed.
Plan of Correction: ?Completed and Fully Compliant: An audit of all staff health records was completed 12/19/2025. All current staff have a TB in files.
?Implement a tracking system to monitor TB test expiration dates and notify staff prior to expiration beginning immediately. Center management will work with Human Resources to utilize a tracking system that can notify employees of their required certifications and tests. Ongoing.
?Implement a tracking system to monitor TB test expiration dates and notify staff prior to expiration beginning immediately. Center management will work with Human Resources to utilize a tracking system that can notify employees of their required certifications and tests. Ongoing.
Standard 8VAC20-780-280-B
Hazardous substances must be in a locked place that prevents access by children.
Multi-purpose solution was found in an unlocked, open closet in classroom #3, accessible to five children.
Multi-purpose solution was found in an unlocked, open closet in classroom #3, accessible to five children.
Plan of Correction: ?A bottle of contact solution was found in the closet on the fourth shelf was immediately discarded while the inspector was on site. Any hazardous items will be secured in locked place that prevents access by children.
?Assistant Director and/or Program Manager will conduct random classroom checks will occur throughout the day to ensure compliance. Management will provide posted checklists as reminders. Ongoing.
?Retrain staff on proper storage of hazardous materials during staff meetings. Completed.
?Assistant Director and/or Program Manager will conduct random classroom checks will occur throughout the day to ensure compliance. Management will provide posted checklists as reminders. Ongoing.
?Retrain staff on proper storage of hazardous materials during staff meetings. Completed.
Standard 8VAC20-780-520-C
REPEAT VIOLATION
If diaper ointment or cream is used, the following requirements shall be met: labeled with the child's name.
Child #25's diaper cream was observed unlabeled in the changing area in Classroom #3.
If diaper ointment or cream is used, the following requirements shall be met: labeled with the child's name.
Child #25's diaper cream was observed unlabeled in the changing area in Classroom #3.
Plan of Correction: ?Issue was addressed immediately during site visit. The tube of Eucerin gel was for a child who has chronic itchy skin. The tube has the child's name and date taped to the tube.
?Center to ensure all diaper ointments and creams are clearly labeled with each child's name immediately. Completed.
?Remove any unlabeled products from classrooms until properly labeled. Completed.
?Re-train staff on medication and ointment storage requirements by 12/16/202 completed.
?Assistant Director and/or Program Manager will conduct random classroom checks will occur throughout the day to ensure compliance. Management will provide posted checklists as reminders. Ongoing.
?Center to ensure all diaper ointments and creams are clearly labeled with each child's name immediately. Completed.
?Remove any unlabeled products from classrooms until properly labeled. Completed.
?Re-train staff on medication and ointment storage requirements by 12/16/202 completed.
?Assistant Director and/or Program Manager will conduct random classroom checks will occur throughout the day to ensure compliance. Management will provide posted checklists as reminders. Ongoing.
Standard 8VAC20-780-60-A
REPEAT VIOLATION
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the following information:
Work phone number and place of employment of each parent who has custody.
Child #4 enrolled and attending for six weeks did not have work phone numbers listed for both parents.
Documentation of viewing proof of the child's identity and age.
Child #4 enrolled and attending for six weeks did not have evidence of proof of identity verification in their record.
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the following information:
Work phone number and place of employment of each parent who has custody.
Child #4 enrolled and attending for six weeks did not have work phone numbers listed for both parents.
Documentation of viewing proof of the child's identity and age.
Child #4 enrolled and attending for six weeks did not have evidence of proof of identity verification in their record.
Plan of Correction: ?Parent does have a work phone number and neglected to mark that section N/A on her form. Center reviewed and form was updated. Completed.
?Review all current children's files to identify missing parent employment information and proof of child's identity and age by 12/22/2025.
?Request and obtain missing documentation from families and place in child files on
12/22/2025.
?Updating enrollment checklist and packet to ensure all required documentation is collected prior to a child's first day of attendance effective immediately.
?Assistant Director will review new enrollment files for completeness upon enrollment.
?Review all current children's files to identify missing parent employment information and proof of child's identity and age by 12/22/2025.
?Request and obtain missing documentation from families and place in child files on
12/22/2025.
?Updating enrollment checklist and packet to ensure all required documentation is collected prior to a child's first day of attendance effective immediately.
?Assistant Director will review new enrollment files for completeness upon enrollment.
Standard 8VAC20-780-70
REPEAT VIOLATION
SYSTEMIC DEFICIENCY
The following staff records shall be kept for each staff person:
Documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position.
Staff #1 did not have evidence of education on file.
Documentation that two or more references as to character and reputation as well as competency were checked before employment shall be kept for each staff person.
Staff #5 employed for 39 months did not have documentation of completed reference verifications.
Documentation to demonstrate that the individual completed orientation training.
Staff #5 employed 39 months did not have evidence of completing orientation.
SYSTEMIC DEFICIENCY
The following staff records shall be kept for each staff person:
Documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position.
Staff #1 did not have evidence of education on file.
Documentation that two or more references as to character and reputation as well as competency were checked before employment shall be kept for each staff person.
Staff #5 employed for 39 months did not have documentation of completed reference verifications.
Documentation to demonstrate that the individual completed orientation training.
Staff #5 employed 39 months did not have evidence of completing orientation.
Plan of Correction: Center management clarified issues with licensing inspector during the inspection in support of future compliance:
?Staff #1 is an Aide who meets all background qualifications and required ECE trainings. Staff #1 had a high school diploma but lost it. Staff #1 ordered a new HS diploma and should be receive within 30 days.
?Staff #5 was hired as a Seasonal Aide as a high school student. As it was her first job, references were not available. Current references are currently in the file. Center clarified that Staff #5 works only on a seasonal/ occasional basis and has not been employed for 39 months consecutively. Staff# 5 last worked at Laurel in August 2025. She returned on November 25 and 26, 2025 as an aide during the Thanksgiving school break.
To ensure continued compliance:
?Audit and File Completion: Center management will conduct a full audit of all staff files to ensure that the education credentials, experience documentation and reference checks have been properly filed, and that all items required during the onboarding or orientation timeline are completed on time. Audit by 12/22/2025.
?Quarterly File Audit: Assistant Director will complete a file audit quarterly to review upcoming training or re-certifications required. Assistant Director and Director will be supported in this through automated tracking available through our human resources management system.
?Orientation/Onboarding Compliance: Ensure all new hires complete orientation and documentation requirements prior to working independently with children. Human Resources and Center Director will ensure compliance. Implemented immediately and with automated process with HR.
?Coordination with Human Resources: Refining process of support through Human Resources to address new hire and seasonal staff re-hire requirements. Procedures will outline responsibilities by Center and/or Human Resources for:
o Pre-employment documentation (background checks, references)
o Orientation and on-boarding documentation (Attestation form, required tests)
o Teacher training and certifications (within the specified period by statute).
?Staff #1 is an Aide who meets all background qualifications and required ECE trainings. Staff #1 had a high school diploma but lost it. Staff #1 ordered a new HS diploma and should be receive within 30 days.
?Staff #5 was hired as a Seasonal Aide as a high school student. As it was her first job, references were not available. Current references are currently in the file. Center clarified that Staff #5 works only on a seasonal/ occasional basis and has not been employed for 39 months consecutively. Staff# 5 last worked at Laurel in August 2025. She returned on November 25 and 26, 2025 as an aide during the Thanksgiving school break.
To ensure continued compliance:
?Audit and File Completion: Center management will conduct a full audit of all staff files to ensure that the education credentials, experience documentation and reference checks have been properly filed, and that all items required during the onboarding or orientation timeline are completed on time. Audit by 12/22/2025.
?Quarterly File Audit: Assistant Director will complete a file audit quarterly to review upcoming training or re-certifications required. Assistant Director and Director will be supported in this through automated tracking available through our human resources management system.
?Orientation/Onboarding Compliance: Ensure all new hires complete orientation and documentation requirements prior to working independently with children. Human Resources and Center Director will ensure compliance. Implemented immediately and with automated process with HR.
?Coordination with Human Resources: Refining process of support through Human Resources to address new hire and seasonal staff re-hire requirements. Procedures will outline responsibilities by Center and/or Human Resources for:
o Pre-employment documentation (background checks, references)
o Orientation and on-boarding documentation (Attestation form, required tests)
o Teacher training and certifications (within the specified period by statute).
Standard 8VAC20-780-80-A
REPEAT VIOLATION
SYSTEMIC DEFICIENCY
Classroom #5's attendance record for December 4, 2025, did not document Child #6, Child #7, Child #8, Child #9, Child #10, Child #11, Child #12, and Child #13 departure as it occurred.
Classroom #6's attendance record for December 4, 2025, did not document Child #14, Child #15, Child #16 Child #17, Child #18, Child #19, Child #20, Child #21, Child #22, and Child #23 departure as it occurred. On December 10, 2025, Child #24 departure was not documented as it occurred.
SYSTEMIC DEFICIENCY
Classroom #5's attendance record for December 4, 2025, did not document Child #6, Child #7, Child #8, Child #9, Child #10, Child #11, Child #12, and Child #13 departure as it occurred.
Classroom #6's attendance record for December 4, 2025, did not document Child #14, Child #15, Child #16 Child #17, Child #18, Child #19, Child #20, Child #21, Child #22, and Child #23 departure as it occurred. On December 10, 2025, Child #24 departure was not documented as it occurred.
Plan of Correction: Laurel Learning Center is implementing a new tracking system using Procare Attendance Tracker that can be used by classroom staff via a phone and by parents through a phone application to ensure daily attendance and tracking of all arrivals and departures are documented as they occur. The Director and/or Assistant Director will review reports on a daily basis and a name to face, spot check every hour.
?Retrain all staff on proper documentation requirements and in using the new systems. Training on Lead Teacher, Aide and Center management responsibilities and use of the attendance tracker will occur during the period 12/19/2025 through 12/22/2025, and will be fully implemented on 12/23/2025.
?Held Parent's meeting (12/18/25) to make parents aware of their responsibility for attendance tracking. Parents agreed to utilize Procare Attendance Tracker and will receive procedures for downloading the application and utilizing phone app. Procedures and training will take place 12/29/2026- 12/31/2026 for full implementation by parents the week of 1/4/2026.
?Retrain all staff on proper documentation requirements and in using the new systems. Training on Lead Teacher, Aide and Center management responsibilities and use of the attendance tracker will occur during the period 12/19/2025 through 12/22/2025, and will be fully implemented on 12/23/2025.
?Held Parent's meeting (12/18/25) to make parents aware of their responsibility for attendance tracking. Parents agreed to utilize Procare Attendance Tracker and will receive procedures for downloading the application and utilizing phone app. Procedures and training will take place 12/29/2026- 12/31/2026 for full implementation by parents the week of 1/4/2026.