Inspection · 2025-03-05
Date
2025-03-05
Complaint Related
No
Licensing Inspector
Stacy Doyle
(571) 835-0386
(571) 835-0386
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.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
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 and completed on 3/05/2025. The on-site inspection began at 8:50am and ended at 12:48pm. The inspector reviewed compliance in the areas listed above. There were 62 children present and 12 staff. The inspector reviewed 5 children?s records and 5 staff records on-site on 3/05/2025. 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.
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 3/12/2025. A POC submitted after this date will not appear on the public website.
Violations
18Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employee's first day of employment.
Staff #6, received a completed national criminal background check one week after the employee's first day of employment .
Staff #6, received a completed national criminal background check one week after the employee's first day of employment .
Plan of Correction: Employee had a copy of previous background check until the new one
was received. Noted to ensure background checks will be received
prior to hire date
was received. Noted to ensure background checks will be received
prior to hire date
Standard 22.1-289.035-B-3
Repeat Violation
For staff hired before July 1, 2024, centers must obtain the results of a central registry search for an employee, within 30 days of service.
Staff #7, who had been employed for two years and two months, did not have central registry search results in their file. Staff stated they had one that was expired and had sent a request for an updated one, but did not have it in the file.
For staff hired before July 1, 2024, centers must obtain the results of a central registry search for an employee, within 30 days of service.
Staff #7, who had been employed for two years and two months, did not have central registry search results in their file. Staff stated they had one that was expired and had sent a request for an updated one, but did not have it in the file.
Plan of Correction: For the future will keep the expired result until the new one is
received. Central Registry changed their portal credentials and took
longer to send the results. I understand that a copy of the request does not
suffice.
received. Central Registry changed their portal credentials and took
longer to send the results. I understand that a copy of the request does not
suffice.
Standard 8VAC20-780-160-A
Repeat Violation
Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with the children and the documentation shall have been completed within the last 30 calendar days of the date of employment .
The screening or test for Staff #2 was completed one year and three months prior to hire.
Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with the children and the documentation shall have been completed within the last 30 calendar days of the date of employment .
The screening or test for Staff #2 was completed one year and three months prior to hire.
Plan of Correction: Noted to comply with future new
hires
hires
Standard 8VAC20-780-240-A
Repeat Violation
Staff are to complete the VDOE sponsored online orientation course within 90 days of hire.
Staff #2 has not completed the course and has been employed 120 days.
Staff are to complete the VDOE sponsored online orientation course within 90 days of hire.
Staff #2 has not completed the course and has been employed 120 days.
Plan of Correction: Staff was reminded and is given a period of time to complete
course
course
Standard 8VAC20-780-245-I
Training on the center's emergency preparedness plan shall be completed annually and each time the plan is updated by all staff.
Staff stated they had not completed training on the center's emergency preparedness plan annually and each time the plan is updated.
Staff stated they had not completed training on the center's emergency preparedness plan annually and each time the plan is updated.
Plan of Correction: Scheduled to address at next
staff meeting
staff meeting
Standard 8VAC20-780-280-B
Repeat Violation
Hazardous substances must be in a locked place that prevents access by children.
In Classroom B, two Lysol bottles were in an unlocked cabinet above the sink.out of reach of children.
In Classroom A, two Lysol bottles were in a cabinet that had a lock on it, but when the cabinet was pulled, the lock did not work and fell off.
In Classroom C bathroom, one Lysol bottle and one sanitizing spray was in an unlocked cabinet out of reach of children.
In the Toddler Classroom bathroom, Clorox and Mr. Clean were in an unlocked cabinet out of reach of children.
Hazardous substances must be in a locked place that prevents access by children.
In Classroom B, two Lysol bottles were in an unlocked cabinet above the sink.out of reach of children.
In Classroom A, two Lysol bottles were in a cabinet that had a lock on it, but when the cabinet was pulled, the lock did not work and fell off.
In Classroom C bathroom, one Lysol bottle and one sanitizing spray was in an unlocked cabinet out of reach of children.
In the Toddler Classroom bathroom, Clorox and Mr. Clean were in an unlocked cabinet out of reach of children.
Plan of Correction: Cleaning substances are placed out of reach of children. New locks
purchased for all cabinets.
purchased for all cabinets.
Standard 8VAC20-780-40-I
The center shall develop written procedures for injury prevention.
Staff stated they had not developed written procedures for injury prevention.
Staff stated they had not developed written procedures for injury prevention.
Plan of Correction: Completed
Standard 8VAC20-780-40-M
The center is required to maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions documented in the allergy plan required in 8VAC20-780-60 A 8. This list shall be dated and kept confidential in each room or area where children are present.
Each classroom had a list of children's allergies, sensitivities and dietary restrictions for the children enrolled in their class only. It was also not updated with current information. Child #6, Child #9 and Child #11 were listed with a food allergy, but it was a preference.
Each classroom had a list of children's allergies, sensitivities and dietary restrictions for the children enrolled in their class only. It was also not updated with current information. Child #6, Child #9 and Child #11 were listed with a food allergy, but it was a preference.
Plan of Correction: List was made and shared with all
staff
staff
Standard 8VAC20-780-420-E-3
Repeat Violation
Staff shall request at least annually parent confirmation that the required information in the child's record is up to date. Up-to-date information is required to be requested from the parent for each child's record at least annually.
The information in the record of child #2 had not been updated in over 2 years and 6 months which is overdue by one year and 6 months.
Staff shall request at least annually parent confirmation that the required information in the child's record is up to date. Up-to-date information is required to be requested from the parent for each child's record at least annually.
The information in the record of child #2 had not been updated in over 2 years and 6 months which is overdue by one year and 6 months.
Plan of Correction: Requested from all parents
Standard 8VAC20-780-500-A
Children?s hands shall be washed with soap and running water or disposable
wipes before and after eating meals or snacks.
In Classroom C, two children were observed eating snack and then taking their dish to the sink to rinse it and place by the sink, but they did not wash their hands.
wipes before and after eating meals or snacks.
In Classroom C, two children were observed eating snack and then taking their dish to the sink to rinse it and place by the sink, but they did not wash their hands.
Plan of Correction: Reviewed handwashing with
the children
the children
Standard 8VAC20-780-500-B
A nonabsorbent surface for diapering or changing shall be used.
In the Toddler classroom, the changing pad had 2 large cracks and 1 small crack on the surface of the changing pad and was absorbent.
In the Toddler classroom, the changing pad had 2 large cracks and 1 small crack on the surface of the changing pad and was absorbent.
Plan of Correction: New changing pad ordered
Delivery date
03/24 - 04/7
Delivery date
03/24 - 04/7
Standard 8VAC20-780-550-D
Repeat Violation
The center shall implement a monthly practice evacuation drill.
The Center failed to implement a monthly practice evacuation drill the following months:
November 2024, December 2024, January 2025 and February 2025.
The center shall implement a monthly practice evacuation drill.
The Center failed to implement a monthly practice evacuation drill the following months:
November 2024, December 2024, January 2025 and February 2025.
Plan of Correction: Will perform practice drill monthly moving forward
Standard 8VAC20-780-550-E
Repeat Violation
Shelter in place procedures shall be practiced a minimum of twice per year.
The center practiced Shelter in Place procedures on 11/26/2024 only.
Shelter in place procedures shall be practiced a minimum of twice per year.
The center practiced Shelter in Place procedures on 11/26/2024 only.
Plan of Correction: Scheduled to practice
Standard 8VAC20-780-550-F
Repeat Violation
Lockdown procedures shall be practiced at least annually.
The center did not practice a lockdown procedure in 2024.
Lockdown procedures shall be practiced at least annually.
The center did not practice a lockdown procedure in 2024.
Plan of Correction: Reviewed procedure with staff and scheduled for upcoming week
Standard 8VAC20-780-560-F
When centers choose to provide meals or snacks, the following shall apply: Centers shall follow the most recent, age-appropriate nutritional requirements of the Child and Adult Care Food Program of the United States Department of Agriculture (USDA) and must have a menu listing foods to be served for meals and snacks during the current one-week period.
Staff stated the center provides afternoon snacks and it was not listed on the center's menu. Staff stated they only serve one component for afternoon snack. USA guidelines requires two components for snacks.
Staff stated the center provides afternoon snacks and it was not listed on the center's menu. Staff stated they only serve one component for afternoon snack. USA guidelines requires two components for snacks.
Plan of Correction: Menu updated
Standard 8VAC20-780-60-A-8
Repeat Violation
A written care plan is required for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
Child #1, Child #2 and Child #12, has a diagnosed food allergy and did not have a written care plan in their file with instructions from a physician.
A written care plan is required for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
Child #1, Child #2 and Child #12, has a diagnosed food allergy and did not have a written care plan in their file with instructions from a physician.
Plan of Correction: Parents have been notified to send physician instructions and care plan
Letters sent out 03-07-2025 with due
date of 04-07-2025
Letters sent out 03-07-2025 with due
date of 04-07-2025
Standard 8VAC20-780-70
Repeat Violation
Each staff record shall be kept with all the required documents including the following:
Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment, the name, address, and telephone number of a person to be notified in an emergency and date of separation from employment
Staff #1, who was no longer employed, did not have the date of separation from employment in their file.
Staff #4, who has been actively working at the center for the past 3 1/2 years, had only one reference on file. The 2nd reference was filled out during the inspection.
Staff #5, who has been actively working at the center for the past 10 years, did not have any completed reference verifications on file. Two references were filled out during the inspection.
Staff #8, who has been actively working at the center for the past 1 1/2 years, did not have any completed reference verifications on file. Two references were filled out during the inspection and did not have the emergency contact name, address and telephone number.
Staff #9, who has been actively working at the center for the past 1 1/2 years, did not have the emergency contact address.
Each staff record shall be kept with all the required documents including the following:
Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment, the name, address, and telephone number of a person to be notified in an emergency and date of separation from employment
Staff #1, who was no longer employed, did not have the date of separation from employment in their file.
Staff #4, who has been actively working at the center for the past 3 1/2 years, had only one reference on file. The 2nd reference was filled out during the inspection.
Staff #5, who has been actively working at the center for the past 10 years, did not have any completed reference verifications on file. Two references were filled out during the inspection.
Staff #8, who has been actively working at the center for the past 1 1/2 years, did not have any completed reference verifications on file. Two references were filled out during the inspection and did not have the emergency contact name, address and telephone number.
Staff #9, who has been actively working at the center for the past 1 1/2 years, did not have the emergency contact address.
Plan of Correction: Records are updated
Standard 8VAC20-780-80-A
Repeat Violation
For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
At approximately 8:54am on 3/05/2025, there were 16 children present in Classroom B and no children were marked present on the attendance record. The staff stated they were busing with children arriving.
For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
At approximately 8:54am on 3/05/2025, there were 16 children present in Classroom B and no children were marked present on the attendance record. The staff stated they were busing with children arriving.
Plan of Correction: All classrooms have attendance records.