Inspection · 2025-06-11
Licensing Inspector
Michele Patchett
(757) 439-6816
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
3VAC20-780 Administration.
3VAC20-780 Staff Qualifications and Training. 3VAC20-780 Physical Plant.
3VAC20-780 Staffing and Supervision. 3VAC20-780 Programs.
3VAC20-780 Special Care Provisions and Emergencies 3VAC20-780 Special Services.
3VAC20-820 THE LICENSE.
3VAC20-820 THE LICENSING PROCESS.
3VAC20-820 HEARINGS PROCEDURES.
3VAC20-770 Background Checks
33.2 Child Abuse & Neglect
22.1 Early Childhood Care and Education 20 Access to minor's records
During the inspection, the inspector reviewed the areas listed above to include standards found out
of compliance during the previous nspection. Unless otherwise noted as a violation within this
inspection report, the provider was in compliance with the standards reviewed. If ,here 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-sitet mandated monitoring inspection ion was initiated on 06/11/2025 and completed on 06/24/2025. The on-site inspection began at 3:30pm and ended at 5:30pm. The inspector reviewed compliance in the areas listed above. There were 54 children present and 3 staff. The inspector reviewed 9 children's records and 8 staff records on-site and on 6/24/2025 reviewed some staff records remotely. This inspection included document review , tour of the facility,interviews,observations, and measurements.
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 06/30/2025. A POC
submitted after this date will not appear on the public website.
Standard 22.1-289.035-B-2
The center must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #5, was working alone with children but the center was unable to provide a national criminal background check results during the inspection.
Plan of Correction: Criminal Background check received on 5/27/2025. Placed in staff file.
Standard 22.1-289.035-B-3
The center must request a search of the central registry prior to the employee's first day of employment. Staff #3, who had been employed for 4 weeks, did not have a documentation of results of central registry. Staff #3 was working alone with children.
Plan of Correction: CRS requested upon hiring. Staff member will be partnered with a staff who has CRS.
Standard 8VAC20-780-160-A
Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment. Staff #7 had no documentation in record provided during the inspection .
Plan of Correction: Staff deadline fir updated TB is 6/30/2025. Will require TB test upon hiring.
Standard 8VAC20-780-160-C
A tuberculosis (TB) screening is required every two years from the last screening. Staff #4 updated screening was due 15 days ago and Staff #6 updated screening was due 5 months ago. The updated screenings was not available to be provided during the inspection.
Plan of Correction: Staff deadline for updated TB IS 6/30/2025.
Standard 8VAC20-780-240-A
Staff are to complete the VDOE sponsored online orientation course within 90 days of hire. Staff #4 record did not have certificate or documentation that Pre-service was completed.
Plan of Correction: Deadline for training is 6/30/2025.
Standard 8VAC20-780-280-B
Hazardous substances must be in a locked place that prevents access by children. In the director office, the aerosol disinfectant spray and hand sanitizer were in the office on the shelf the door was open . In the 2nd building, in the bathroom there was a cabinet that was not locked and had multiple chemicals under the sink.
Plan of Correction: Substances removed and locked away.
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 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.
The centers allergy list did not have a date.
Plan of Correction: Allergy list be updated and dated monthly.
Standard 8VAC20-780-540-E
One working, battery-operated radio in each building used by children and any camp location without a building.
The center did not have a one working battery operated radio in each building used by children and camp location without a building. They had three buildings in use for the program.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-550-P
The enter's written record of children's serious and minor injuries in which entries are made the day occurrence. The record shall have all required information.
Injury record #1, #2 and #3 was missing two signatures, future action , staff present and time notified and how parent was notified .
Plan of Correction: Updated report available for site with correct information.