Inspection · 2025-02-10
Licensing Inspector
Cindy Horne
(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 2/10/2025. The on-site inspection began at 11:00 a.m. and ended at 2:55 p.m. The inspector reviewed compliance in the areas listed above. There were 34 children present and seven staff. The inspector reviewed five children?s records and five staff records on site. This inspection included document review (i.e. daily schedule, menu, license, previous inspection, attendance records, injury reports, emergency drill logs), 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 2/25/2025. A POC submitted after this date will not appear on the public website.
Standard 8VAC20-780-240-B
Staff shall complete orientation training addressing elements listed under 8VAC20-78-0-240.C prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Staff Number 4 has been working for almost 17 months and there was no documentation of a completed orientation in the record. Staff Number 5 has been working for almost 15 months and there was no documentation of a completed orientation in the record.
Plan of Correction: Our Employee Orientation has been evaluated and our Corporate office has created an onboarding plan that is tracked online and available to managers. All new employees will go through the same process and receive the same training documents.
Standard 8VAC20-780-245-A
(Repeat Violation) Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. Staff #4 did not obtain 16 required training hours in 2024.
Plan of Correction: We are developing a system of tracking our staff members' trainings and ensuring that all hours are completed each year. Also, we will review with the staff that all training certificates need to be turned in to a manager as soon as they are obtained so that there is proof they were completed.
Standard 8VAC20-780-70
Staff records must include documentation to demonstrate that the individual possesses the education and experience required by the job position. The record for Staff 3 did not include transcripts or a copy of their high school diploma.
Plan of Correction: A full audit of all staff files will be completed and a checklist will be used to ensure that all required items are in each staff member's file.