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The Village at Leafspring School at Three Chopt

Inspection · 2025-04-15

Date
2025-04-15
Complaint Related
No
Licensing Inspector
Lauren Bickford
(540) 280-0742
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 Physical Plant.
63.2 Child Abuse & Neglect
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 renewal inspection was initiated on 04/15/2025 and completed on 04/15/2025. The on-site inspection began at 1:55pm and ended at 4:54pm. The inspector reviewed compliance in the areas listed above. There were 107 children present and 13 staff. The inspector reviewed 10 children?s records and 10 staff records on-site. This inspection included document review, and tour of the facility.

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 (5) business days from today, which will be the close of business on 04/22/2025. A POC submitted after this date will not appear on the public website.

Violations

4
Standard 22.1-289.035-B-4
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.

Staff #9, employed for four months, did not have documentation of requesting a central registry check from one state. Staff was working and responsible for a group of children.
Plan of Correction: We have created a profile and sent employee link to complete individual check. Employee will submit request today 4.22.25
Standard 8VAC20-780-130-B
The center may allow a child to attend contingent upon a conditional enrollment for a period of 90 days if the child received at least one dose of each of the required vaccines and the child possesses a plan from a physician or local health department for completing his immunization requirements within the ensuing 90 calendar days.

Additional immunizations for child #9?s conditional enrollment was due four months ago.
Plan of Correction: The parents were notified on 4.14.25 that an updated record was needed. Was given two weeks to submit it.
Standard 8VAC20-780-40-E
Repeat Violation:
The operational responsibilities of the licensee shall include ensuring that the center's activities, services, and facilities are maintained in compliance with these standards, the center's own policies and procedures that are required by these standards, and the terms of the current license issued by the department.

The center's medication policy states that "Prescription and non-prescription medication is returned to the parent as soon as the medication is no longer being administered or if the medication is expired." Child #11 had emergency medication that expired February of 2025, and had not yet been returned to the parents.
Plan of Correction: An audit will be completed of all current meds and our tracking system updated if any errors in records are found. Medication was updated by parents and are current. Old meds were returned.
Standard 8VAC20-780-510-H
Nonprescription medication shall be in the original container with the direction label attached.

Nonprescription medication for Child #11 was not in its original container.
Plan of Correction: Original container was added to child's meds.
View original record on Virginia Department of Social Services