Inspection · 2025-09-22
Date
2025-09-22
Complaint Related
No
Licensing Inspector
Sarah Marbert
(703) 479-4678
(703) 479-4678
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.
8VAC20-770 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 9/22/25 as a part of licensure period. The on-site inspection began at 11:15 AM and ended at 3:45PM. The inspector reviewed compliance in the areas listed above. There were 83 children present and 22 staff. The inspector reviewed 5 child and 7 staff records on-site.
This inspection included: document review, a 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 10/6/25. A POC submitted after this date will not appear on the public website.
Violations
12Standard 22.1-289.035-B-4
Repeat Violation
The center is required to obtain background checks from any state in which the individual has resided in the previous five years.
Staff B, employed for more than 11 months did not have a child abuse and neglect search
for a residence outside of Virginia in the past 5 years.
Staff D's sex offender search result on file was overdue by 4 weeks when it was conducted.
Staff F, employed for five months did not have the results of a sex offender search on file, and did not have the results of a child abuse and neglect search for a residence outside of Virginia in the past 5 years.
The center is required to obtain background checks from any state in which the individual has resided in the previous five years.
Staff B, employed for more than 11 months did not have a child abuse and neglect search
for a residence outside of Virginia in the past 5 years.
Staff D's sex offender search result on file was overdue by 4 weeks when it was conducted.
Staff F, employed for five months did not have the results of a sex offender search on file, and did not have the results of a child abuse and neglect search for a residence outside of Virginia in the past 5 years.
Plan of Correction: Staff F?s sex offender search was immediately obtained and placed in the. The Child Abuse and Neglect search from out of State was obtained and placed in the file on 9/30/2025.
Going forward the Center Director will follow a checklist of all required clearances and make sure they are all obtained and placed in employee?s file before employee starts working.
Going forward the Center Director will follow a checklist of all required clearances and make sure they are all obtained and placed in employee?s file before employee starts working.
Standard 8VAC20-780-160-A
Each staff member and individual from an independent contractor shall submit documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted at the time of employment and shall have been completed within the last 30 calendar days of the date of employment.
*Staff E's record contained documentation of a negative screening result that was overdue by 5 days.
*Staff F's record contained no results. Results were overdue by 5 months.
*Staff E's record contained documentation of a negative screening result that was overdue by 5 days.
*Staff F's record contained no results. Results were overdue by 5 months.
Plan of Correction: Moving Forward
TB Tests/Screening**
Staff must provide a TB test or screening before their start date.
The Center Director and Assistant Director will monitor compliance for all new employees
TB Tests/Screening**
Staff must provide a TB test or screening before their start date.
The Center Director and Assistant Director will monitor compliance for all new employees
Standard 8VAC20-780-240-A
The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment.
3 staff had no documentation of completing the VDOE sponsored course.
Staff C's documentation was overdue by 2 weeks.
Staff E's documentation was overdue by 2 months.
Staff F's documentation was overdue by 2 months.
3 staff had no documentation of completing the VDOE sponsored course.
Staff C's documentation was overdue by 2 weeks.
Staff E's documentation was overdue by 2 months.
Staff F's documentation was overdue by 2 months.
Plan of Correction: Immediate Act
ion Staff C, Staff E, and Staff F were required to present certificates of
completion by Friday October 3, 2025
Moving Forward
Virginia 10 hour training must be completed before entering the classroom, during
the first week of orientation
The Center Director or Assistant Director will ensure a **printed certificate** is
available before the end of t he first week of orientation for new staff.
ion Staff C, Staff E, and Staff F were required to present certificates of
completion by Friday October 3, 2025
Moving Forward
Virginia 10 hour training must be completed before entering the classroom, during
the first week of orientation
The Center Director or Assistant Director will ensure a **printed certificate** is
available before the end of t he first week of orientation for new staff.
Standard 8VAC20-780-240-B
Staff shall complete orientation training in subsection C of this section prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.
Staff F's orientation documentation on file was overdue by 3 weeks.
Staff F's orientation documentation on file was overdue by 3 weeks.
Plan of Correction: Moving Forward
Employee Transfers**
For employees transferring from another center, obtain and review a complete file
from the previous program.
This process must be completed before the transfer is finalized and before the
employee's first day at the new center.
Ensure all necessary out of state checks and orientation requirements are fulfilled
during the transfer process.
Employee Transfers**
For employees transferring from another center, obtain and review a complete file
from the previous program.
This process must be completed before the transfer is finalized and before the
employee's first day at the new center.
Ensure all necessary out of state checks and orientation requirements are fulfilled
during the transfer process.
Standard 8VAC20-780-40-E
Repeat Violation
The operational responsibilities of the licensee shall include ensuring that the center's activities are maintained in compliance with the center's own policies and procedures that are required by these standards.
The facility did not follow its own policy for medication administration of returning expired medications, when it did not return expired medication to the family.
*Child #11 had a medication at the center that was expired by 7 months.
The operational responsibilities of the licensee shall include ensuring that the center's activities are maintained in compliance with the center's own policies and procedures that are required by these standards.
The facility did not follow its own policy for medication administration of returning expired medications, when it did not return expired medication to the family.
*Child #11 had a medication at the center that was expired by 7 months.
Plan of Correction: Child #11
Family was notified immediately and medication was returned to family. Fami ly were in structed to provide unexpired medication.
Moving Forward
Review of allergy plans and medications will take place on the **30th of every
month**. This review is to be completed before the allergy list is posted on the **1st of the following month**. A reminder for this review will be added to the Center Director and Assistant Directors? Outlook calendars.
Family was notified immediately and medication was returned to family. Fami ly were in structed to provide unexpired medication.
Moving Forward
Review of allergy plans and medications will take place on the **30th of every
month**. This review is to be completed before the allergy list is posted on the **1st of the following month**. A reminder for this review will be added to the Center Director and Assistant Directors? Outlook calendars.
Standard 8VAC20-780-40-M
The center shall 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 required allergy plan. This list shall be dated and kept confidential in each room or area where children are present.
The allergy list for the center dated September 2025 was not current. Two children were listed in the wrong rooms.
The allergy list for the center dated September 2025 was not current. Two children were listed in the wrong rooms.
Plan of Correction: Immediate action
Allergy Plan was corrected the same day 9/22/2025 to list all children in the correct
room.
Moving Forward
Review of allergy plans and medications will take place on the **30th of every
month**. This review is to be completed before the allergy list is posted on the **1st of the following month**. A reminder for this review will be added to the Center Director and Assistant Directors? Outlook calendars.
Allergy Plan was corrected the same day 9/22/2025 to list all children in the correct
room.
Moving Forward
Review of allergy plans and medications will take place on the **30th of every
month**. This review is to be completed before the allergy list is posted on the **1st of the following month**. A reminder for this review will be added to the Center Director and Assistant Directors? Outlook calendars.
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.
*Child #2's record was overdue for an annual update by 7 weeks.
*Child #4's record was overdue for an annual update by 4 weeks.
*Child #10's allergy action plan update was overdue by 6 months.
*Child #12's allergy action plan update was overdue by 2 months.
Staff shall request at least annually parent confirmation that the required information in the child's record is up to date.
*Child #2's record was overdue for an annual update by 7 weeks.
*Child #4's record was overdue for an annual update by 4 weeks.
*Child #10's allergy action plan update was overdue by 6 months.
*Child #12's allergy action plan update was overdue by 2 months.
Plan of Correction: Immediate Action Complete child file audit was condu
cted on we ek 9/30/2025 any overdue
forms were updated . Overdue Action plans were updated immediately
Moving Forward
Child Records
Electronic records will be updated, printed and placed in child files as completed by parents. Any overdue forms brought to the attention of families and assistance will to complete them will be done at the center.
cted on we ek 9/30/2025 any overdue
forms were updated . Overdue Action plans were updated immediately
Moving Forward
Child Records
Electronic records will be updated, printed and placed in child files as completed by parents. Any overdue forms brought to the attention of families and assistance will to complete them will be done at the center.
Standard 8VAC20-780-440-B
Cribs, cots, rest mats, and beds shall be identified for use by a specific child.
An occupied crib in the Infant 1 room was not identified for use by a specific child.
An occupied crib in the Infant 1 room was not identified for use by a specific child.
Plan of Correction: Immediate Action
Crib was labeled immediately 9/22/2025
Moving forward
All Crib and cot label s will be made prior to children first date of attendance
Crib was labeled immediately 9/22/2025
Moving forward
All Crib and cot label s will be made prior to children first date of attendance
Standard 8VAC20-780-510-F
The medication authorization shall be available to staff during the entire time it is effective.
Child #8 had no medication authorization available for a medication that was on site.
Child #8 had no medication authorization available for a medication that was on site.
Plan of Correction: Immediate Action
Medication was removed medication on 9/22/2025 and sent home with family
Moving Forward
Review of medications will take place on the **30th of every month**. A reminder for this review will be added to the Center Director and Assistant Directors? Outlook
calendars.
Medication was removed medication on 9/22/2025 and sent home with family
Moving Forward
Review of medications will take place on the **30th of every month**. A reminder for this review will be added to the Center Director and Assistant Directors? Outlook
calendars.
Standard 8VAC20-780-510-P
Repeat Violation
Systemic Deficiency
When an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization.
No new authorizations had been completed.
*Child #12'smedication authorizations expired 7/12/25 (2 medications)
Systemic Deficiency
When an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization.
No new authorizations had been completed.
*Child #12'smedication authorizations expired 7/12/25 (2 medications)
Plan of Correction: Child # 11?s parents were contacted immediately, and new updated authorizations were provided by parents on 9/23/2025 and placed in the child?s file. Child # 12?s parents were contacted immediately, and new updated authorizations were provided by parents on 9/23/2025 and placed in the child?s file.
Going forward the Center Director will create a spreadsheet of due dates of all medication authorizations for children and check it monthly to send reminders to parents to provide updated authorizations before the authorizations expire.
Going forward the Center Director will create a spreadsheet of due dates of all medication authorizations for children and check it monthly to send reminders to parents to provide updated authorizations before the authorizations expire.
Standard 8VAC20-780-550-P
The center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include the following: Staff and parent signatures or two staff signatures.
3 injury reports reviewed were not signed by either 2 staff, or a parent and staff.
3 injury reports reviewed were not signed by either 2 staff, or a parent and staff.
Plan of Correction: Moving forward
All reports will be printed by the CD and AD and signatures will be acquired wi thin 24 hours. A bind er will kept with all origami reports.
All reports will be printed by the CD and AD and signatures will be acquired wi thin 24 hours. A bind er will kept with all origami reports.
Standard 8VAC20-780-70
The following staff records shall be kept for each staff person: verification of age, 2 references conducted prior to employment. If a reference is taken over the phone, the signature of the person making the call.
Staff C, D, E, F and G's records had no verification of age on file.
Staff C, D, E, F and G's records contained references taken over the phone. There was no signature of the person making the call documented.
Staff C, D, E, F and G's records had no verification of age on file.
Staff C, D, E, F and G's records contained references taken over the phone. There was no signature of the person making the call documented.
Plan of Correction: Immediate Actions
Staff C,D,E,F and G
provided proof of age 9/29/2025. Center Director9/30/2025 verified
references for Staff C, D, E, and F.
Moving forward Center Director will call and verify third party references for all employees before the first date of employment.
Staff C,D,E,F and G
provided proof of age 9/29/2025. Center Director9/30/2025 verified
references for Staff C, D, E, and F.
Moving forward Center Director will call and verify third party references for all employees before the first date of employment.