Inspection · 2025-02-13
Date
2025-02-13
Complaint Related
No
Licensing Inspector
Cindy Horne
(804) 297-4469
(804) 297-4469
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
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
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 and completed on 2/13/2025. The on-site inspection began at 11:30 a.m. and ended at 3:00 p.m. The inspector reviewed compliance in the areas listed above. There were 18 children present and four staff. The inspector reviewed five children?s records and six staff records on site. This inspection included document review (i.e. daily schedule, menu, license, previous inspection, attendance records, injury reports, emergency drill logs, medication administration logs, and authorization forms), 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.
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 business days from today, which will be the close of business on 3/11/2025. A POC submitted after this date will not appear on the public website.
Violations
14Standard 8VAC20-780-160-C
(Repeat/Systemic Violation) A tuberculosis (TB) screening is required every two years from the last screening. The updated screening for Staff #2 was due 4 months ago. The updated screening has not yet been completed.
Plan of Correction: See Intensive Plan of Correction
Standard 8VAC20-780-245-A
Staff shall complete annually a minimum of 16 hours of training appropriate to
the age of children in care. Staff #2 did not complete 16 hours of annual training in 2024.
the age of children in care. Staff #2 did not complete 16 hours of annual training in 2024.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-260-A
(Repeat/Systemic Violation) The center shall provide to the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction. The most recent fire inspection was dated 5/02/2023.
Plan of Correction: See Intensive Plan of Correction
Standard 8VAC20-780-260-B
Annual approval from the health department shall be provided for meeting requirements for the water supply and the sewage disposal system. The center has not contacted the health department to obtain a Report of Environmental Sanitation.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-270-A
The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition. There was peeling paint in the classroom for the 2 and 3 year old children on the walls, baseboards, and cubbies that was accessible to children.
Plan of Correction: See Intensive Plan of Correction
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 these
standards and the center's own policies and procedures that are required by these
standards. The center did not ensure that Staff #6 followed their policies regarding storage and labeling of medication, staff training required for administration of medication, obtaining medication authorizations, and maintaining a record of medication administration. Staff #6 stated on 2/13/25 that she has been administering medication through an inhaler to Child #5 twice a day for approximately one month. The medication was not kept in a safe locked place out of the reach of children. Their policy requires medication to ?be kept under lock and key?. The medication was stored in a plastic bag in the child?s backpack in the classroom. The medication was not maintained in the ?original container? as their policy requires. The medication had no prescription label with the name of Child #5 on it. Their policy requires prescriptions to ?have the child?s name, dosage, and times to be given with the current expiration date?. There were no instructions regarding dosage, frequency, or manner of administration. Staff #6 has not completed MAT training. Their policy requires ?permission from parents? to administer medication. The center did not have a medication authorization form signed by the parents of Child #5 and no written record had been maintained that documented to whom the medication was administered, the amount and type of medication administered, the day and time the medication was administered, the staff member who administered the medication or any adverse reactions or medication errors. The center did not complete a ?log of medication administration? as their policy requires.
center's activities, services, and facilities are maintained in compliance with these
standards and the center's own policies and procedures that are required by these
standards. The center did not ensure that Staff #6 followed their policies regarding storage and labeling of medication, staff training required for administration of medication, obtaining medication authorizations, and maintaining a record of medication administration. Staff #6 stated on 2/13/25 that she has been administering medication through an inhaler to Child #5 twice a day for approximately one month. The medication was not kept in a safe locked place out of the reach of children. Their policy requires medication to ?be kept under lock and key?. The medication was stored in a plastic bag in the child?s backpack in the classroom. The medication was not maintained in the ?original container? as their policy requires. The medication had no prescription label with the name of Child #5 on it. Their policy requires prescriptions to ?have the child?s name, dosage, and times to be given with the current expiration date?. There were no instructions regarding dosage, frequency, or manner of administration. Staff #6 has not completed MAT training. Their policy requires ?permission from parents? to administer medication. The center did not have a medication authorization form signed by the parents of Child #5 and no written record had been maintained that documented to whom the medication was administered, the amount and type of medication administered, the day and time the medication was administered, the staff member who administered the medication or any adverse reactions or medication errors. The center did not complete a ?log of medication administration? as their policy requires.
Plan of Correction: See Intensive Plan of Correction
Standard 8VAC20-780-40-H
(Repeat/Systemic Violation) The sponsor shall maintain public liability insurance for bodily injury for each center site with a minimum limit of at least $500,000 each occurrence and with a minimum limit of $500,000 aggregate. The director was unable to provide documentation of liability insurance.
Plan of Correction: See Intensive Plan of Correction
Standard 8VAC20-780-40-M
The center shall maintain a current written list of all children's allergies, sensitivities, and dietary restrictions in each room where children are present. The director stated on 2/13/25 that the allergy list posted in the center?s classrooms was, "not current" and the list was not dated.
Plan of Correction: See Intensive Plan of Correction
Standard 8VAC20-780-510-I
The center may administer prescription medication that would normally be
administered by a parent or guardian to a child provided: the medication is administered by a staff member who has completed Medication Administration Training; the center has obtained written authorization from a parent; the center administers only those drugs that were dispensed from a pharmacy and maintained in the original, labeled container; and the center administers drugs only to the child identified on the prescription label in accordance with the prescriber's instructions.
Staff #6 stated on 2/13/25 that she has been administering medication through an inhaler to Child #5 twice a day for approximately one month. Staff #6 has not completed MAT training. The center did not have written authorization from the parents of Child #5 to administer the medication. The medication was not maintained in the original labeled container. The medication had no prescription label so there were no instructions regarding dosage, frequency, or manner of administration.
administered by a parent or guardian to a child provided: the medication is administered by a staff member who has completed Medication Administration Training; the center has obtained written authorization from a parent; the center administers only those drugs that were dispensed from a pharmacy and maintained in the original, labeled container; and the center administers drugs only to the child identified on the prescription label in accordance with the prescriber's instructions.
Staff #6 stated on 2/13/25 that she has been administering medication through an inhaler to Child #5 twice a day for approximately one month. Staff #6 has not completed MAT training. The center did not have written authorization from the parents of Child #5 to administer the medication. The medication was not maintained in the original labeled container. The medication had no prescription label so there were no instructions regarding dosage, frequency, or manner of administration.
Plan of Correction: See Intensive Plan of Correction
Standard 8VAC20-780-510-L
Medication shall be kept in a locked place using a safe locking method that prevents access by children. The medication that Staff #6 administered to Child #5 was not kept in a locked place using a safe locking method that prevents access by children. The medication was kept in the child?s backpack in the classroom.
Plan of Correction: See Intensive Plan of Correction
Standard 8VAC20-780-510-N
Centers shall keep a record of medication given children, which shall include the following: the child to whom medication was administered; amount and type of medication administered to the child; the day and time the medication was administered to the child; staff member administering the medication; any adverse reactions; and any medication errors. Staff #6 stated on 2/13/25 that she has been administering medication through an inhaler to Child #5 twice a day for approximately one month. There were no written records documenting that the medication had been administered to Child #5.
Plan of Correction: See Intensive Plan of Correction
Standard 8VAC20-780-550-E
The center is required to practice shelter in place procedures a minimum of twice per year. There was one shelter in place drill conducted in 2024 on 2/28/2024.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-K
The center shall prepare a document containing local emergency contact information, potential shelters, hospitals, evacuation routes, etc., that pertain to each site frequently visited or of routes frequently driven by center staff for center business such as field trips or pick up or drop off of children to or from schools etc. This document must be kept in vehicles that centers use to transport children to and from the center. This information was not kept in the vehicle used to transport children that was inspected on 2/13/25. The director stated on 2/13/25 that she did not know that this information needed to be prepared and kept in the vans they use to transport children.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-60-A
Each center shall maintain a separate record for each child enrolled that contains all required information.
The records for Child #2, Child #3, Child #4, and Child #5 did not contain the name, address or phone number of the second parent. The record for Child #3 did not contain the name, address, and phone number of two designated people to call in an emergency. The record of Child #5 did not have appropriate legal paperwork when the custodial parent requests the center not to release the child to the other parent. The record of Child #4 did not include annual parent confirmation that the required information in the child?s file is up to date. The last update was dated 8/04/23. The record of Child #2 did not contain a written agreement with the parent regarding authorization for emergency medical care, procedures when a child is ill, or procedures regarding communicable diseases.
The records for Child #2, Child #3, Child #4, and Child #5 did not contain the name, address or phone number of the second parent. The record for Child #3 did not contain the name, address, and phone number of two designated people to call in an emergency. The record of Child #5 did not have appropriate legal paperwork when the custodial parent requests the center not to release the child to the other parent. The record of Child #4 did not include annual parent confirmation that the required information in the child?s file is up to date. The last update was dated 8/04/23. The record of Child #2 did not contain a written agreement with the parent regarding authorization for emergency medical care, procedures when a child is ill, or procedures regarding communicable diseases.
Plan of Correction: Not available online. Contact Inspector for more information.